Specially formulated compositions of inhaled nintedanib and nintedanib salts

ABSTRACT

Disclosed herein are formulations of nintedanib and salts thereof, indolinone derivative compounds and salts thereof for aerosolization and use of such formulations for the prevention or treatment of various fibrotic, carcinogenic, vascular and viral infectious diseases, including diseases associated with the lung, heart, kidney, liver, eye, central nervous system and surgical sites. Formulations and delivery options described herein allow for efficacious local delivery of nintedanib or a indolinone derivative compound or salt thereof. Methods include inhalation procedures, indications and manufacturing processes for production and use of the compositions described. Also included are methods for identifying compounds and indications that benefit by reformulation and inhalation administration.

BACKGROUND OF THE INVENTION

Despite development of a number of promising therapies, a numberpulmonary diseases such as interstitial lung disease (ild; and sub-classdiseases therein), cancer, vascular and many viral infectious diseaseremain unmet clinical needs. Additionally, a number of extrapulmonarydiseases may also benefit from inhaled delivery of nintedanib. However,development of advanced nintedanib formulations for delivery byinhalation carries a number of challenges that have not been completelyovercome.

SUMMARY

Special design considerations for nintedanib impact a number ofparameters that are critical for developing an inhaled therapeuticproduct. By selective manipulation of formulation parameters and aerosoldevice parameters, the target organ dose, pharmacokinetic profile, andsafety profile can be improved to increase efficacy, safety and maximizepatient compliance. Described herein are compositions of nintedanib orsalt thereof, and indolinone derivatives or salt thereof that aresuitable for inhalation delivery to the lungs, central nervous systemand/or systemic compartment and methods of use.

Specially formulated nintedanib or nintedanib salt solutions, orindolinone derivatives or salts thereof formulation composition andpackaging for oral inhaled or intranasal inhaled delivery for theprevention or treatment of various diseases, including diseaseassociated with the lung, heart, kidney, liver, eye and central nervoussystem, including fibrosis, cancers, and vascular diseases.

The invention includes an aqueous dosing solution for nebulizedinhalation administration comprising water; nintedanib or salt thereof,or a indolinone derivative or salt thereof at a concentration from about0.005 mg/mL to about 10 mg/mL and optionally one or more osmolalityadjusting agents at a concentration of about 0.1% to about 20% to adjustosmolality, inorganic salts at a concentration of about 15 mM to about300 mM to adjust osmolality and provide a permeant ion at a finalconcentration from about 30 mM to about 150 mM; and optionally one ormore buffers to maintain the pH between about pH 3.0 to about pH 7.0,preferably from about pH 3.0 to about pH 6.0, with a final osmolalitybetween 50 mOsmo/kg and 600 mOsmo/kg. The aqueous solution may includeone or more osmolality adjusting agents, including co-solvents selectedfrom propylene glycol, ethanol and mannitol and combinations thereof ata concentration from about 0.1% to about 20%. The aqueous solutionincludes one more inorganic salts selected from sodium chloride,magnesium chloride, calcium chloride, potassium chloride, sodiumbromide, potassium bromide, magnesium bromide and calcium bromide andcombinations thereof. The inorganic salt content of the aqueous solutionis from about 15 mM to about 300 mM. The buffer is selected from one ormore of lysinate, acetylcysteine, glycine, glutamate, borate, succinate,tartrate, phosphate or Tris and combinations thereof, the pH of theaqueous solution is from about pH 3.0 to about pH 7.0, preferably pHabout 3.0 to about pH 6.0.Described herein are an aqueous solution fornebulized inhalation administration comprising: water; nintedanib orsalt thereof, at a concentration from about 0.005 mg/mL to about 10mg/mL; one or more permeant ions at a concentration from about 30 mM to150 mM; one or more osmolality adjusting agents; and wherein theosmolality of the aqueous solution is from about 50 mOsmol/kg to about600 mOsmol/kg. The formulation may be administered as an inhaled aerosolcreated from a dosing volume ranging from about 0.01 mL to about 10 mL.The formulation may be administered as an inhaled aerosol over a fewbreaths or by tidal breathing up to 20 minutes.

The invention includes a multi-container system for admixture wherein anaqueous solution of nintedanib or salt thereof, or indolinone derivativeis formulated in a container separate from other components of a finalsolution that is aerosolized in in a liquid nebulizer. The firstcontainer comprises nintedanib or salt thereof, or a indolinonederivative or salt thereof at a concentration from about 0.005 mg/mL toabout 10 mg/mL; optionally water; optionally more or more buffers at aconcentration from about 1 mM to about 1000 mM; optionally, one or moreosmolality adjusting agentsat a concentration from about 0.1% to about99%; and optionally one or more taste-masking agents at a concentrationfrom about 0.1% to about 90%. A second container comprises one of moreinorganic salts at a concentration from about 15 mM to about 1500 mM,providing a permeant ion concentration from about 30 mM to about 1500mM; optionally water; optionally one or more buffers at a concentrationfrom about 1 mM to about 1000 mM; optionally, one or more osmolalityadjusting agents at a concentration from about 0.1% to about 99%; andoptionally one or more taste-masking agents at a concentration fromabout 0.1% to about 90 mM. Admixture of the containers provides anaqueous dosing solution for nebulized inhalation administrationcomprising water; nintedanib or salt thereof, or a indolinone derivativeor salt thereof at a concentration from about 0.005 mg/mL to about 10mg/mL,—and optionally one or more osmolality adjusting agents at aconcentration of about 0.1% to about 20% to adjust osmolality, inorganicsalts at a concentration of about 15 mM to about 300 mM to adjustosmolality and provide a permeant ion at a final concentration fromabout 30 mM to about 150 mM; and optionally one or more buffers tomaintain the pH between about pH 3.0 to about pH 7.0, preferably fromabout pH 3.0 to about pH 6.0, with a final osmolality between 50mOsmo/kg and 600 mOsmo/kg. The aqueous solution may include one or moreosmolality adjusting agents including co-solvents selected frompropylene glycol, ethanol and mannitol and combinations thereof at aconcentration from about 0.1% to about 20%. The aqueous solutionincludes one more inorganic salts selected from sodium chloride,magnesium chloride, calcium chloride, potassium chloride, sodiumbromide, potassium bromide, magnesium bromide and calcium bromide andcombinations thereof. The inorganic salt content of the aqueous solutionis from about 15 mM to about 300 mM and the buffer is selected from oneor more of lysinate, acetylcysteine, glycine, glutamate, borate,succinate, tartrate, phosphate or Tris and combinations thereof, the pHof the aqueous solution is from about pH 3.0 to about pH 7.0, preferablypH about 3.0 to about pH 6.0. Described herein is an aqueous solutionfor nebulized inhalation administration comprising: water; nintedanib orsalt thereof, at a concentration from about 0.005 mg/mL to about 10mg/mL, preferably not exceeding 5.0 mg/mL; one or more permeant ions ata concentration from about 30 mM to about 150 mM; one or more osmolalityadjusting agents; and wherein the osmolality of the aqueous solution isfrom about 50 mOsmol/kg to about 600 mOsmol/kg. Admixed formulation iseither mixed prior to and poured into the nebulization device, may beseparately poured and mixed within the nebulization device, or admixedwithin a container serving as the nebulization device medicinereservoir. The admixed formulation may be administered as an inhaledaerosol created from a dosing volume ranging from about 0.01 mL to about10 mL. The admixed formulation may be administered as an inhaled aerosolover a few breaths or by tidal breathing up to 20 minutes. The rationalefor the multi-container system is that the required parameters of thefinal solution for aerosolization, including specifically the pH, andion concentration, buffer content, osmolality, or other parameter mayrequire solutes that are incompatible with nintedanib or indolinonecomposition as the active pharmaceutical ingredient. By maintaining thecompositions in separate containers, until prior to admixture andintroduction into the nebulizer or administration, the stability of theactive ingredient is maintained.

The invention includes a stand-alone, single-container system whereinnintedanib or salt thereof, or an indolinone derivative are stabilizedin the presence of pH, and ion concentration, buffer content,osmolality, or other parameters that are otherwise incompatible withnintedanib or indolinone composition as the active pharmaceuticalingredient. The addition of the active ingredient pirfenidone orpyridone analog further increases nintedanib or indolinone compositionstability, increases aqueous solubility, and reduces viscosity thatotherwise exists at high nintedanib or indolinone compositionconcentrations greater than about 10 mg/mL to about 50 mg/mL. At theseand lower nintedanib or salt thereof, or an indolinone derivativeconcentrations, the addition of active ingredient pirfenidone orpyridone analog enables formulation of nintedanib or salt thereof, or anindolinone derivative in a stable, single container solution containingion concentrations, buffer contents, osmolality, pH or other parametersthat are otherwise incompatible as a single solution product. For this,the formulation as administered may be prepared as a unit dosage adaptedfor use in a liquid nebulizer comprising from about 0.01 mL to about 10mL of an aqueous solution of nintedanib or salt thereof, or a indolinonederivative or salt thereof at a concentration from about 0.005 mg/mL toabout 50 mg/mL, and pirfenidone or pyridone analog at a concentrationfrom about 5 mg/mL to about 20 mg/mL, optionally one or more osmolalityadjusting agents at a concentration of about 0.1% to about 20% to adjustosmolality, inorganic salts at a concentration of about 15 mM to about500 mM to adjust osmolality and provide a permeant ion at a finalconcentration from about 30 mM to about 500 mM; and optionally one ormore buffers to maintain the pH between about pH 3.0 to about pH 7.0,preferably from about pH 3.0 to about pH 6.0, with a final osmolalitybetween 50 mOsmo/kg and 1000 mOsmo/kg. The aqueous solution may includeone or more osmolality adjusting agents including co-solvents selectedfrom propylene glycol, ethanol, glycerin, and mannitol and combinationsthereof at a concentration from about 0.1% to about 20%. The aqueoussolution includes one more inorganic salts selected from sodiumchloride, magnesium chloride, calcium chloride, potassium chloride,sodium bromide, potassium bromide, magnesium bromide and calcium bromideand combinations thereof. The inorganic salt content of the aqueoussolution is from about 15 mM to about 300 mM. The buffer is selectedfrom one or more of lysinate, acetylcysteine, glycine, glutamate,borate, succinate, tartrate, phosphate or Tris and combinations thereof,the pH of the aqueous solution is from about pH 3.0 to about pH 7.0,preferably pH about 3.0 to about pH 6.0.Described herein is an aqueoussolution for nebulized inhalation administration comprising: water;nintedanib or salt thereof, at a concentration from about 0.005 mg/mL toabout 50 mg/mL; pirfenidone or pyridone analog at a concentration fromabout 5 mg/mL to about 20 mg/mL; one or more permeant ions; one or moreosmolality adjusting agents; and wherein the osmolality of the aqueoussolution is from about 50 mOsmol/kg to about 1000 mOsmol/kg. Theformulation may be administered as an inhaled aerosol created from adosing volume ranging from about 0.01 mL to about 10 mL. The formulationmay be administered as an inhaled aerosol over a few breaths or by tidalbreathing up to 20 minutes.

The special formulation parameters of the invention include theselection of the salt for complexation with the form of nintedanib usedfor an isolated solution. Preferred salts include esylate, chloride, andbromide. The total delivery dose is from about 0.01 mL to about 10 mL ofthe aqueous solution described herein.

The invention includes a kit comprising: a unit dosage of an aqueoussolution of nintedanib or salt thereof, as described herein in acontainer that is adapted for use with a liquid nebulizer such that thecontents of a single container or multiple containers are combined inanticipation of placing the combined solution in the reservoir of aliquid nebulizer for aerosolization.

Moreover, the physicochemical properties of the resulting aerosolcreated by the compositions and methods of the present invention are animportant part of the therapeutic utility of the present inventionbecause the specially selected formulation design parameters, togetherwith aerosolization by the nebulizer structures as described below,yield an aerosol mist that has uniquely advantageous properties fordelivery of the active ingredient to a pulmonary compartment that istailored to the pharmacodynamic absorption of the active pharmaceuticalingredient in the pulmonary organ. An aerosolized aqueous solution formsa population of nintedanib or indolinone of salt thereof, or nintedanibor indolinone of salt thereof and pirfenidone or pyridone analog whereinthe aqueous droplet has a diameter less than about 5.0 μm. The aqueousdroplet produced from a final solution placed in a liquid nebulizer,formulated as the specially designed solution containing nintedanib orindolinone or salt thereof has a concentration from about 0.005 mg/mL toabout 10 mg/mL and an osmolality from about 50 mOsmol/kg to about 600mOsmol/kg. Alternatively, the aqueous droplet produced from a finalsolution placed in a liquid nebulizer, formulated as the speciallydesigned solution containing nintedanib or indolinone or salt thereofhas a concentration from about 0.005 mg/mL to about 50 mg/mL andpirfenidone or pyridone analog at a concentration from about 5 mg/mL toabout 20 mg/mL and an osmolality from about 50 mOsmol/kg to about 1000mOsmol/kg.

These and other aspects of the invention will be evident upon referenceto the following detailed description. All of the U.S. patents, U.S.patent application publications, U.S. patent applications, foreignpatents, foreign patent applications and non-patent publicationsreferred to in this specification, are incorporated herein by referencein their entirety, as if each was incorporated individually.

Certain Terminology

The term “mg” refers to milligram.

The term “mcg” refers to microgram.

The term “microM” refers to micromolar.

As used herein, the term “about” is used synonymously with the term“approximately.” Illustratively, the use of the term “about” with regardto a certain therapeutically effective pharmaceutical dose indicatesthat values slightly outside the cited values, e.g., plus or minus 0.1%to 10%, which are also effective and safe.

As used herein, the terms “comprising,” “including,” “such as,” and “forexample” are used in their open, non-limiting sense.

The terms “administration” or “administering” and “delivery” or“delivery” refer to a method of giving to a human a dosage of atherapeutic or prophylactic formulation, such as an nintedanib or saltthereof formulation described herein, for example as ananti-inflammatory, anti-fibrotic and/or anti-demyelinationpharmaceutical composition, or for other purposes. The preferreddelivery method or method of administration can vary depending onvarious factors, e.g., the components of the pharmaceutical composition,the desired site at which the formulation is to be introduced, deliveredor administered, the site where therapeutic benefit is sought, or theproximity of the initial delivery site to the downstream diseased organ(e.g., aerosol delivery to the lung for absorption and secondarydelivery to the heart, kidney, liver, central nervous system or otherdiseased destination).

The terms “pulmonary administration” or “inhalation” or “pulmonarydelivery” or “oral inhalation” or “intranasal inhalation” and otherrelated terms refer to a method of delivering to a human a dosage of atherapeutic or prophylactic formulation by a route such that the desiredtherapeutic or prophylactic agent is delivered to the lungs of a human.

The terms “intranasal administration” and “intranasal delivery” refer toa method of giving to a mammal a dosage of a therapeutic or prophylacticformulation, such as an nintedanib or salt thereof formulation describedherein, by a route such that the desired therapeutic or prophylacticagent is delivered to the nasal cavity or diseased organs downstream(e.g., aerosol delivery to the nasal cavity for absorption and secondarydelivery to the central nervous system or other diseased destination).Such delivery to the nasal cavity may occur by intranasaladministration, wherein this route of administration may occur asinhalation of an aerosol of formulations described herein, injection ofan aerosol of formulations described herein, gavage of a formulationdescribed herein, or passively delivered by mechanical ventilation.

The term “abnormal liver function” may manifest as abnormalities inlevels of biomarkers of liver function, including alanine transaminase,aspartate transaminase, bilirubin, and/or alkaline phosphatase, and isan indicator of drug-induced liver injury. See FDA Draft Guidance forIndustry. Drug-Induced Liver Injury: Premarketing Clinical Evaluation,October 2007.

“Grade 2 liver function abnormalities” include elevations in alaninetransaminase (ALT), aspartate transaminase (AST), alkaline phosphatase(ALP), or gamma-glutamyl transferase (GGT) greater than 2.5-times andless than or equal to 5-times the upper limit of normal (ULN). Grade 2liver function abnormalities also include elevations of bilirubin levelsgreater than 1.5-times and less than or equal to 3-times the ULN.

“Gastrointestinal adverse events” include but are not limited to any oneor more of the following: dyspepsia, nausea, diarrhea, gastroesophagealreflux disease (GERD) and vomiting.

A “carrier” or “excipient” is a compound or material used to facilitateadministration of the compound, for example, to increase the solubilityof the compound. Solid carriers include, e.g., starch, lactose,dicalcium phosphate, sucrose, and kaolin. Liquid carriers include, e.g.,sterile water, saline, buffers, non-ionic surfactants, and edible oilssuch as oil, peanut and sesame oils. In addition, various adjuvants suchas are commonly used in the art may be included. These and other suchcompounds are described in the literature, e.g., in the Merck Index,Merck & Company, Rahway, N.J. Considerations for the inclusion ofvarious components in pharmaceutical compositions are described, e.g.,in Gilman et al. (Eds.) (1990); Goodman and Gilman's: ThePharmacological Basis of Therapeutics, 8th Ed., Pergamon Press.

A “diagnostic” as used herein is a compound, method, system, or devicethat assists in the identification and characterization of a health ordisease state. The diagnostic can be used in standard assays as is knownin the art.

The term “ex vivo” refers to experimentation or manipulation done in oron living tissue in an artificial environment outside the organism.

The term “pH-reducing acid” refers to acids that retain the biologicaleffectiveness and properties of the compounds of this invention and,which are not biologically or otherwise undesirable. Pharmaceuticallyacceptable pH-reducing acids include, for example, inorganic acids suchas, e.g., hydrochloric acid, hydrobromic acid, sulfuric acid, nitricacid, phosphoric acid, and the like. Also by nonlimiting example,pH-reducing acids may also include organic acids such as acetic acid,propionic acid, naphtoic acid, oleic acid, palmitic acid, pamoic(emboic) acid, stearic acid, glycolic acid, pyruvic acid, oxalic acid,malonic acid, succinic acid, tartaric acid, ascorbic acid, glucoheptonicacid, glucuronic acid, lactic acid, lactobioic acid, tartaric acid,benzoic acid, cinnamic acid, mandelic acid, methanesulfonic acid,ethanesulfonic acid, p-toluenesulfonic acid, salicylic acid, and thelike. According to certain herein disclosed embodiments an nintedanib ora indolinone derivative compound formulation may comprise an “acidicexcipient” that is typically present as an acidic excipient aqueoussolution. Examples of may include acid salts such as phosphate,sulphate, nitrate, acetate, formate, tartrate, propionate and sorbate,organic acids such as carboxylic acids, sulfonic acids, phosphonicacids, phosphinic acids, phosphoric monoesters, and phosphoric diesters,and/or other organic acids that contain from 1 to 12 carbon atoms,acetic acid, propionic acid, butyric acid, benzoic acid, mono-, di-, andtrichloroacetic acid, salicylic acid, trifluoroacetic acid,benzenesulfonic acid, toluenesulfonic acid, methylphosphonic acid,methylphosphinic acid, dimethylphosphinic acid, and phosphonic acidmonobutyl ester.

A “buffer” refers to a compound that functions to regulate pH. Incertain related embodiments the pH buffer is present under conditionsand in sufficient quantity to maintain a pH that is “about” a recited pHvalue. “About” such a pH refers to the functional presence of thatbuffer, which, as is known in the art, is a consequence of a variety offactors including pKa value(s) of the buffer, buffer concentration,working temperature, effects of other components of the composition onpKa (i.e., the pH at which the buffer is at equilibrium betweenprotonated and deprotonated forms, typically the center of the effectivebuffering range of pH values), and other factors.

Hence, “about” in the context of pH may be understood to represent aquantitative variation in pH that may be more or less than the recitedvalue by no more than 0.5 pH units, more preferably no more than 0.4 pHunits, more preferably no more than 0.3 pH units, still more preferablyno more than 0.2 pH units, and most preferably no more than 0.1-0.15 pHunits. As also noted above, in certain embodiments a substantiallyconstant pH (e.g., a pH that is maintained within the recited range foran extended time period) may be from about pH 4.0 to about pH 7.0, fromabout pH 4.0 to about pH 7.0, or from about pH 4.0 to about pH 6.8, orany other pH or pH range as described herein, which in preferredembodiments may be from about pH 4.0 to about pH 7.0 for an nintedanibor salt thereof formulation, and greater than about pH 7.0.

Therefore the pH buffer typically may comprise a composition that, whenpresent under appropriate conditions and in sufficient quantity, iscapable of maintaining a desired pH level as may be selected by thosefamiliar with the art, for example, buffers comprising, lysinate,acetylcysteine, glycine, glutamate, borate, succinate, tartrate,phosphate or Tris formate, pyridine, piperazine, succinate, histidine,bis-Tris, pyrophosphate, PIPES, ACES, histidine, MES, cacodylic acid,H2CO3/NaHCO3 and N-(2-Acetamido)-2-iminodiacetic acid (ADA) or otherbuffers for maintaining, preserving, enhancing, protecting or otherwisepromoting desired biological or pharmacological activity of annintedanib or indolinone salt thereof. Suitable buffers may includethose listed herein or known to the art (see, e.g., Calbiochem®Biochemicals & Immunochemicals Catalog 2004/2005, pp. 68-69 and catalogpages cited therein, EMD Biosciences, La Jolla, Calif.).

“Solvate” refers to the compound formed by the interaction of a solventand nintedanib or an indolinone derivative compound, a metabolite, orsalt thereof. Suitable solvates are pharmaceutically acceptable solvatesincluding hydrates.

By “therapeutically effective amount” or “pharmaceutically effectiveamount” is meant nintedanib or a indolinone or salt that are useful intreatment of humans in therapeutically effective amounts and thatproduce the desired therapeutic effect as judged by clinical trialresults and/or model animal pulmonary fibrosis, lung transplantrejection-associated chronic lung allograft dysfunction (CLAD) andrestrictive allograft syndrome (RAS), cardiac fibrosis, kidney fibrosis,hepatic fibrosis, heart or kidney toxicity, or disease resulting fromactive, previous or latent viral infection.

A “therapeutic effect” relieves, to some extent, one or more of thesymptoms associated with inflammation, fibrosis and/or demyelination.This includes slowing the progression of, or preventing or reducingadditional inflammation, fibrosis and/or demyelination. For IPF and RAS,a “therapeutic effect” is defined as a reduced decline in forced vitalcapacity (FVC), and/or a patient-reported improvement in quality of lifeand/or a statistically significant increase in or stabilization ofexercise tolerance and associated blood-oxygen saturation, reduceddecline in baseline forced vital capacity, decreased incidence in acuteexacerbations, increase in progression-free survival, increasedtime-to-death or disease progression, and/or reduced lung fibrosis. ForCLAD, a “therapeutic effect” is defined as a reduced decline in forcedexpiratory volume in one second (FEV1), For cardiac fibrosis, a“therapeutic effect” is defined as a patient-reported improvement inquality of life and/or a statistically significant improvement incardiac function, reduced fibrosis, reduced cardiac stiffness, reducedor reversed valvular stenosis, reduced incidence of arrhythmias and/orreduced atrial or ventricular remodeling. For kidney fibrosis, a“therapeutic effect” is defined as a patient-reported improvement inquality of life and/or a statistically significant improvement inglomular filtration rate and associated markers. For hepatic fibrosis, a“therapeutic effect” is defined as a patient-reported improvement inquality of life and/or a statistically significant lowering of elevatedaminotransferases (e.g., AST and ALT), alkaline phosphatases,gamma-glutamyl transferase, bilirubin, prothrombin time, globulins, aswell as reversal of thromobocytopenia, leukopenia and neutropenia andcoagulation defects. Further a potential reversal of imaging, endoscopicor other pathological findings. For disease resulting from active,previous or latent viral infection, a “therapeutic effect” is defined asa patient-reported improvement in quality of life and/or a statisticallysignificant reduction in viral load, improved exercise capacity andassociated blood-oxygen saturation, FEV1 and/or FVC, a slowed or haltedprogression in the same, progression-free survival, increasedtime-to-death or disease progression, and/or reduced incidence or acuteexacerbation or reduction in neurologic symptoms. The term “prophylactictreatment” refers to treating a patient who is not yet diseased but whois susceptible to, or otherwise at risk of, a particular disease, or whois diseased but whose condition does not worsen while being treated withthe pharmaceutical compositions described herein. The term “therapeutictreatment” refers to administering treatment to a patient alreadysuffering from a disease. Thus, in preferred embodiments, treating isthe administration to a mammal (either for therapeutic or prophylacticpurposes) of therapeutically effective amounts of nintedanib or aindolinone derivative compound.

The “respirable delivered dose” is the amount of aerosolized nintedanibor a indolinone derivative compound particles inhaled during theinspiratory phase of the breath simulator that is equal to or less than5 microns.

“Lung Deposition” as used herein, refers to the fraction of the nominaldose of an active pharmaceutical ingredient (API) that is deposited onthe inner surface of the lungs.

“Nominal dose,” or “loaded dose” refers to the amount of drug that isplaced in the nebulizer prior to administration to a human. The volumeof solution containing the nominal dose is referred to as the “fillvolume.”

“Enhanced pharmacokinetic profile” means an improvement in somepharmacokinetic parameter. Pharmacokinetic parameters that may beimproved include, AUC last, AUC(0-∞) Tmax, and optionally a Cmax. Theenhanced pharmacokinetic profile may be measured quantitatively bycomparing a pharmacokinetic parameter obtained for a nominal dose of anactive pharmaceutical ingredient (API) administered with one type ofinhalation device with the same pharmacokinetic parameter obtained withoral administration of a composition of the same active pharmaceuticalingredient (API).

“Respiratory condition,” as used herein, refers to a disease orcondition that is physically manifested in the respiratory tract,including, but not limited to, pulmonary fibrosis, cancer, diseaseresulting from active, previous or latent viral infection, bronchitis,chronic bronchitis, or emphysema.

“Drug absorption” or simply “absorption” typically refers to the processof movement of drug from site of delivery of a drug across a barrierinto a blood vessel or the site of action, e.g., a drug being absorbedin the pulmonary capillary beds of the alveoli.

DETAILED DESCRIPTION Pulmonary and Regional Diseases

A number of pulmonary diseases such as interstitial lung disease (ILD;and sub-class diseases therein), cancer (lung cancer; and sub-classdiseases therein), fibrotic indications of the lungs, kidney, heart andeye, viral infections and diseases of the central nervous system arecurrent areas of unmet clinical need.

In fibrosis, scarring serves a valuable healing role following injury.However, tissue may become progressively scarred following more chronic,repeated and or idiopathic injuries resulting in abnormal function. Inthe case of idiopathic pulmonary fibrosis (IPF; and other subclasses ofILD), if a sufficient proportion of the lung becomes scarred respiratoryfailure can occur. In any case, progressive scarring may result from arecurrent series of insults to different regions of the organ or afailure to halt the repair process after the injury has healed. In suchcases the scarring process becomes uncontrolled and deregulated. In someforms of fibrosing disease scarring remains localized to a limitedregion, but in others it can affect a more diffuse and extensive arearesulting in direct or associated organ failure.

In epithelial injury, epithelial cells are triggered to release severalpro-fibrotic mediators, including the potent fibroblast growth factorstransforming growth factor-beta (TGF-beta), tumor necrosis factor (TNF),platelet derived growth factor (PDGF), endothelin, other cytokines,metalloproteinases and the coagulation mediator tissue factor.Importantly, the triggered epithelial cell becomes vulnerable toapoptosis, and together with an apparent inability to restore theepithelial cell layer are the most fundamental abnormalities in fibroticdisease.

In conditions such as diseases, physiological responses characterized bycontrol of pro-fibrotic factors with indolinone derivative, such asnintedanib is beneficial to attenuate and/or reverse fibrosis, treatcancer, or central nervous system disease. Therapeutic strategiesexploiting such indolinone derivative and/or nintedanib effects in theseand other indications are contemplated herein.

Nintedanib and Indolinone Derivative Compounds—Therapeutic Utility

The indolinone derivative for use in a indolinone derivative formulationas described herein comprises nintedanib (methyl(3Z)-3-[[4-[methyl-[2-(4-methylpiperazin-1-yl)acetyl]amino]anilino]-phenylmethylidene]-2-oxo-1H-indole-6-carboxylate)or a salt thereof.

Other indolinone derivative compounds, or salts thereof, may be used inplace of nintedanib. Indolinone derivative compounds include, but arenot limited to, those compounds that are structurally similar tonintedanib. Indolinone derivative compounds include, but are not limitedto, those compounds that are structurally similar to and have the sametype of biological activity as nintedanib. Indolinone derivativecompounds include modifications to the nintedanib molecule that areforeseeable based on substitution of chemical moieties that preserve theStructure Activity Relationship (SAR) of nintedanib based on theinteraction of nintedanib, or the subject derivative as specific andselective inhibitor of certain tyrosine kinases as described below.Indolinone derivative compounds include, but are not limited to, thosecompounds described in U.S. Pat. Nos. 6,762,180 and 7,119,093.

Nintedanib inhibits a broad range of kinases at pharmacologicallyrelevant concentrations. Examples of targeted kinases include all threeVEGFR subtypes (VEGFR-1, IC50 34 nM; VEGFR-2, IC50 21 nM; VEGFR-3, IC5013 nM), FGFR types (FGFR-1, IC50 69 nM; FGFR-2, IC50 37 nM; FGFR-3, IC50108 nM; FGFR-4, IC50 610 nM), and PDGFR-α (IC50, 59 nM) and PDGFR-β(IC50, 65 nM). The ability of nintedanib to simultaneously target thesethree, distinct proangiogenic receptor classes may enhance its antitumoreffects and overcome pathways of resistance to VEGF- andVEGFR-2-targeted agents. Nintedanib also inhibited Flt-3 and members ofthe Src-family (Src, Lyn, and Lck), which may have therapeutic potentialfor conditions such as hematologic diseases.

The antifibrotic potential of VEGFR, PDGFR, and FGFR inhibition withorally administered nintedanib has also been evaluated in a series ofpreclinical studies. Nintedanib was shown to inhibit PDGFR-α and PDGFR-βactivation and proliferation of normal human lung fibroblasts in vitroand to inhibit PDGF-BB-, FGF-2-, and VEGF-induced proliferation of humanlung fibroblasts from patients with IPF and control donors. Nintedanibattenuated PDGF- or FGF-2-stimulated migration of lung fibroblasts frompatients with IPF9 and inhibited transforming growth factor(TGF)-β-induced fibroblast to myofibroblast transformation of primaryhuman lung fibroblasts from IPF patients. PDGFR activation anddownstream signaling was inhibited by nintedanib in a dose-dependentmanner in mouse lung tissue when administered orally in vivo. In twodifferent mouse models of IPF, nintedanib exerted anti-inflammatoryeffects as shown by significant reductions in lymphocyte and neutrophilcounts in the bronchoalveolar lavage fluid, reductions in inflammatorycytokines, and reduced inflammation and granuloma formation inhistological analysis of lung tissue. IPF mouse models also revealednintedanib-associated antifibrotic effects as shown by significantreductions in total lung collagen and by reduced fibrosis identified inhistological analyses.

IPF is a chronic and progressive, fibrotic lung disease associated witha short median survival post diagnosis of 2-3 years due to a lack ofeffective therapies. IPF is characterized by uncontrolledfibroblast/myofibroblast proliferation and differentiation, andexcessive collagen deposition within the lung interstitium and alveolarspace, leading to symptoms of cough and dyspnea, and ultimately torespiratory failure.

In some embodiments, administration of nintedanib or indolinone or saltthereof, by inhalation has reduced gastrointestinal and liverside-effects when compared to oral administration. Reducing theseside-effects increases patient safety, maximizes patient compliance,avoids dose reduction and/or stoppage protocols, and enables local lungdose escalation for additional efficacy otherwise not possible with theoral product.

The specially formulated nintedanib or indolinone aqueous solutions foraerosol administration are used in methods of treatment of lung diseasein a human the methods are applied to diseases including, not limitedto, pulmonary fibrosis, idiopathic pulmonary fibrosis, radiation inducedfibrosis, silicosis, asbestos induced pulmonary or pleural fibrosis,acute lung injury, acute respiratory distress syndrome (ARDS),sarcoidosis, usual interstitial pneumonia (UIP), cystic fibrosis,Chronic lymphocytic leukemia (CLL)-associated fibrosis, Hamman-Richsyndrome, Caplan syndrome, coal worker's pneumoconiosis, cryptogenicfibrosing alveolitis, obliterative bronchiolitis, chronic bronchitis,emphysema, pneumonitis, Wegner's granulamatosis, scleroderma-associatedlung fibrosis, systemic sclerosis-associated interstitial lung disease(SSc-ILD), silicosis, interstitial lung disease, asbestos inducedpulmonary and/or pleural fibrosis. In some methods the primary, lungdisease is lung fibrosis (i.e. pulmonary fibrosis), while in othermethodologies the fibrosis is a comorbidity of a separate disease suchas cancer or is the result of a prior infection or surgery, includingparticularly chronic lung allograft dysfunction (CLAD), and includingrestrictive allograft syndrome (RAS).

Pulmonary Fibrosis

A method for treating or preventing progression of pulmonary disease,comprising administering nintedanib or indolinone or salt thereof or incombination with pirfenidone or pyridone analog to a middle to lowerrespiratory tract of a patient having or suspected of having pulmonarydisease through oral inhalation of an aerosol. A method of treating orpreventing progression of interstitial pulmonary fibrosis and includespatients who are being mechanically ventilated.

A method for treating or preventing progression of idiopathic pulmonaryfibrosis (IPF), comprising administering nintedanib or indolinone orsalt thereof or in combination with pirfenidone or pyridone analog to amiddle to lower respiratory tract of a subject having or suspected IPFthrough oral inhalation of an aerosol comprising nintedanib or saltthereof.

A method for treating or preventing progression of systemic sclerosisassociated interstitial lung disease (SSc-ILD), comprising administeringnintedanib or indolinone or salt thereof or in combination withpirfenidone or pyridone analog to a middle to lower respiratory tract ofa subject having or suspected of having SSc-ILD through oral inhalationof an aerosol comprising nintedanib or indolinone or salt thereof.

A method for treating or preventing progression of bronchiolitisobliterans, comprising administering nintedanib or indolinone or saltthereof or in combination with pirfenidone or pyridone analog to amiddle to lower respiratory tract of a patient having or suspected ofhaving bronchiolitis obliterans through oral inhalation of an aerosolcomprising nintedanib or indolinone or salt thereof.

A method for treating or preventing progression of chronic lungallograft dysfunction, comprising administering nintedanib or indolinonesalt thereof or in combination with pirfenidone or pyridone analog to amiddle to lower respiratory tract of a patient having or suspected ofhaving restrictive allograft syndrome through oral inhalation of anaerosol comprising nintedanib or indolinone or salt thereof.

A method for treating or preventing progression of restrictive allograftsyndrome, comprising administering nintedanib indolinone salt thereof orin combination with pirfenidone or pyridone analog to a middle to lowerrespiratory tract of a patient having or suspected of having restrictiveallograft syndrome through oral inhalation of an aerosol comprisingnintedanib or indolinone or salt thereof.

IPF as described herein refers to “idiopathic pulmonary fibrosis” and isin some embodiments a chronic disease that manifests over several yearsand is characterized by scar tissue within the lungs, in the absence ofknown provocation. Exercise-induced breathlessness and chronic dry coughmay be the prominent symptoms. IPF belongs to a family of lung disordersknown as the interstitial lung diseases (ILD) or, more accurately, thediffuse parenchymal lung diseases. Within this broad category of diffuselung diseases, IPF belongs to the subgroup known as idiopathicinterstitial pneumonia (IIP). There are seven distinct IIPs,differentiated by specific clinical features and pathological patterns.IPF is the most common form of IIP. It is associated with the pathologicpattern known as usual interstitial pneumonia (UIP); for that reason,IPF is often referred to as IPF/UIP. IPF is usually fatal, with anaverage survival of approximately three years from the time ofdiagnosis. There is no single test for diagnosing pulmonary fibrosis;several different tests including chest x-ray, pulmonary function test,exercise testing, bronchoscopy and lung biopsy are used in conjunctionwith the methods described herein.

Idiopathic pulmonary fibrosis (also known as cryptogenic fibrosingalveolitis) is the most common form of interstitial lung disease and maybe characterized by chronic progressive pulmonary parenchymal fibrosis.It is a progressive clinical syndrome with unknown etiology; the outcomeis frequently fatal as no effective therapy exists. In some embodiments,nintedanib inhibits fibroblast proliferation and differentiation relatedto collagen synthesis, inhibits the production and activity of TGF-beta,reduces production of fibronectiv and connective tissue growth factor,inhibits TNF-alpha and I-CAM, increase production of IL-10, and/orreduces levels of platelet-derived growth factor (PDGF) A and B inbleomycin-induced lung fibrosis. The methods and compositions describedherein may provide tolerability and usefulness in patients with advancedidiopathic pulmonary fibrosis and other lung diseases. In someembodiments, nintedanib methods and compositions described herein mayprovide tolerability and usefulness in patients with mild to moderateidiopathic pulmonary fibrosis. Increased patient survival, enhancedvital capacity, reduced episodes of acute exacerbation (compared toplacebo), and/or slowed disease progression are observed followingtreatment with the compositions of the invention.

Exemplary fibrotic lung diseases for the treatment or prevention usingthe methods described herein include, but are not limited to, idiopathicpulmonary fibrosis, systemic sclerosis-associated interstitial lungdisease, pulmonary fibrosis secondary to transplant rejection such asbronchiolitis obliterans and restrictive allograft syndrome, systemicinflammatory disease such as rheumatoid arthritis, scleroderma, lupus,cryptogenic fibrosing alveolitis, radiation induced fibrosis,sarcoidosis, scleroderma, chronic asthma, silicosis, asbestos inducedpulmonary or pleural fibrosis, acute lung injury and acute respiratorydistress (including bacterial pneumonia induced, trauma induced, viralpneumonia induced, ventilator induced, non-pulmonary sepsis induced, andaspiration induced).

Where the methods of the invention are applied to treatments orpreventing progression of pulmonary cancer, the disorder includes lungcarcinoid tumors or bronchial cardinoids, primary or secondary lungcancers resulting from metastatic disease, including non-small cell lungcancer, bronchioloalveolar carcinoma, sarcoma, and lymphoma.

Methods of the invention include treatment or prophylaxis of patientsidentified as having gastrointestinal stromal tumors, relapsed orrefractory Ph-positive Acute lymphoblastic leukemia (ALL),myelodysplastic/ myeloproliferative diseases associated withplatelet-derived growth factor receptor gene re-arrangements, aggressivesystemic mastocytosis (ASM) (without or an unknown D816V c-KITmutation), hypereosinophilic syndrome (HES) and/or chronic eosinophilicleukemia (CEL) who have the FIP1L1-PDGFRα fusion kinase (CHIC2 alleledeletion) or FIP1L1-PDGFR-alpha fusion kinase negative or unknown, orunresectable, recurrent and/or metastatic dermatofibrosarcomaprotuberans, and combinations thereof.

In one aspect, described herein is a method for treating neurologicdisease, comprising administering nintedanib or indolinone or saltthereof, to a patient diagnosed or suspected of having neurologicdisease and treated through oral or intranasal inhalation of an aerosolfor pulmonary or nasal vascular absorption and delivery to centralnervous system, including to treat or alleviate neurofibromatosis,neurofibromatosis type I, Alzheimer's disease, the presence of Lewy Bodyproteins or precursors thereof, and combinations thereof and wherein thepatient may exhibit opioid tolerance.

Lung Transplant Rejection

Lung transplant rejection initially manifests as Chronic Lung AllograftDysfunction (CLAD) and is the major cause of mortality. The majorfeature is bronchiolitis obliterans. The rate of decline in lungfunction when severe averaging about 7-fold higher than seen in apatient with idiopathic pulmonary fibrosis (IPF). Some CLAD patients(approximately 30%) develop Restrictive Allograft Syndrome (RAS) whichcarries a worse prognosis. In these patients there is loss of both FVC,forced vital capacity creating restrictive pulmonary function. Thepathophysiology is similar to IPF with progressive interstitialfibrosis.

A method for treating or preventing progression of pulmonary disease,comprising administering nintedanib or indolinone or salt thereof to amiddle to lower respiratory tract of a patient having or suspected ofhaving pulmonary disease through oral inhalation of an aerosol. Themethod includes treating or preventing progression of Chronic LungAllograft Dysfunction (CLAD) as a manifestation of lung transplantrejection. The method includes delivery to patients who are beingmechanically ventilated. The method also includes administration ofnintedanib or indolinone or salt thereof and pirfenidone or pyridoneanalog in combination.

A method for treating or preventing progression of pulmonary disease,comprising administering nintedanib or indolinone or salt thereof to amiddle to lower respiratory tract of a patient having or suspected ofhaving pulmonary disease through oral inhalation of an aerosol. Themethod includes treating or preventing progression of bronchiolitisobliterans as a manifestation of lung transplant rejection. The methodincludes delivery to patients who are being mechanically ventilated. Themethod also includes administration of nintedanib or indolinone or saltthereof and pirfenidone or pyridone analog in combination.

A method for treating or preventing progression of pulmonary disease,comprising administering nintedanib or indolinone or salt thereof to amiddle to lower respiratory tract of a patient having or suspected ofhaving pulmonary disease through oral inhalation of an aerosol. Themethod includes treating or preventing progression of RestrictiveAllograft Syndrome (RAS) as a manifestation of lung transplantrejection. The method includes delivery to patients who are beingmechanically ventilated. The method also includes administration ofnintedanib or indolinone or salt thereof and pirfenidone or pyridoneanalog in combination.

Kidney Fibrosis

A method for treating or preventing progression of an extrapulmonarydisease, comprising administering nintedanib or indolinone or saltthereof, wherein the extrapulmonary disease is kidney fibrosis, and mayresult or be a.co-morbidity chronic infection, obstruction of the ureterby calculi, malignant hypertension, radiation therapy, transplantrejection, severe diabetic conditions, or chronic exposure to heavymetals, and combinations thereof.

The term “kidney fibrosis” by non-limiting example relates to remodelingassociated with or resulting chronic infection, obstruction of theureter by calculi, malignant hypertension, radiation therapy, transplantrejection, severe diabetic conditions or chronic exposure to heavymetals and generally correlates with the overall loss of renal function.

Heart and Kidney Toxicity

A method for treating or preventing progression of an extrapulmonarydisease also includes, heart and kidney damage resulting from treatmentwith other active pharmaceutical ingredients including chemotherapeuticagents that have toxic effects upon multiple organs during therapy. Bynon-limiting example doxorubicin has a broad spectrum of therapeuticactivity against various tumors. However, its clinical use is limited byits undesirable systemic toxicity, especially in the heart and kidney.In some embodiments, because the heart and kidney vasculature areimmediately downstream of the lung, inhaled delivery of nintedanib orindolinone or salt thereof, prevents or alleviates chemotherapy-inducedcardiac and/or renal inflammation without exposing the systemiccompartment to otherwise toxic drug levels associated with oraladministration

Cardiac Fibrosis

A method for treating or preventing progression of an extrapulmonarydisease, includes cardiac fibrosis including remodeling of cardiactissue observed in chronic hypertension and may involve myocytehypertrophy as well as fibrosis, an increased and non-uniform depositionof extracellular matrix proteins. The extracellular matrix connectsmyocytes, aligns contractile elements, prevents overextending anddisruption of myocytes, transmits force and provides tensile strength toprevent rupture. Fibrosis occurs in many models of hypertension leadingto an increased diastolic stiffness, a reduction in cardiac function andan increased risk of arrhythmias If fibrosis rather than myocytehypertrophy is the critical factor in impaired cardiovascular function,then reversal of cardiac fibrosis facilitates return of normal cardiacfunction.

The term “cardiac fibrosis” by non-limiting example relates toremodeling associated with or resulting from viral or bacterialinfection, surgery, Duchenne muscular dystrophy, radiation therapy,chemotherapy, transplant rejection and chronic hypertension wheremyocyte hypertrophy as well as fibrosis is involved and an increased andnon-uniform deposition of extracellular matrix proteins occurs. Fibrosisoccurs in many models of hypertension leading to an increased diastolicstiffness, a reduction in cardiac function, an increased risk ofarrhythmias and impaired cardiovascular function.

Hepatic Fibrosis

A method for treating or preventing progression of an extrapulmonarydisease includes hepatic fibrosis caused by chronic liver disease,including disease caused by non-limiting example persistent viralhepatitis, alcohol overload and autoimmune disorders and combinationsthereof. Hepatic fibrosis involves an abnormal accumulation ofextracellular matrix components, particularly collagens. Hepaticstellate cells are non-parenchymal liver cells residing in theperisinusoidal space. These cells have been shown to be the majorcellular source of extracellular matrix in hepatic fibrosis.

The term “hepatic fibrosis” by non-limiting example may be associatedwith or caused by severe liver damage in patients with chronic liverdisease, caused by non-limiting example persistent viral hepatitis,alcohol overload and autoimmune diseases. Hepatic fibrosis involves anabnormal accumulation of extracellular matrix components, particularlycollagens. Hepatic stellate cells are non-parenchymal liver cellsresiding in the perisinusoidal space.

Glaucoma Surgery Post-Operative Fibrosis

A method for treating or preventing progression of an extrapulmonarydisease includes postoperative fibrosis following, glaucoma filtrationsurgery where the success of the surgery is dependent on the degree ofpost-operative wound healing and the amount of scar tissue formation.Bleb failure occurs as fibroblasts proliferate and migrate toward thewound, eventually causing scarring and closure of the fistula tract.This frequently leads to poor postoperative intraocular pressure controlwith subsequent progressive optic nerve damage. The use of adjunctiveantifibrotic agents such as 5-fluorouracil and mitomycin C hassignificantly improved the success rate of filtration surgery. However,because of their nonspecific mechanisms of action, these agents cancause widespread cell death and apoptosis, resulting in potentiallysight-threatening complications such as severe postoperative hypotony,bleb leaks, and endophthalmitis.

Cancer

Lung cancer mortality is high, and annual lung cancer deaths equalprostate, breast, colon, and rectum cancers combined. Despite theadvancement in knowledge on molecular mechanisms and the introduction ofmultiple new therapeutic lung cancer agents, the dismal 5-year survivalrate (11-15%) remains relatively unaltered. This reflects the limitedavailable knowledge on factors promoting oncogenic transformation to andproliferation of malignant cells.

We now know that tumor growth is not determined only by malignant cells,because interactions between cancer cells and the stromal compartmenthave major impacts on cancer growth and progression. Aggressivemalignant cells are clever at exploiting the tumor microenvironment:tumor cells can (1) reside in the stroma and transform it, (2) alter thesurrounding connective tissue, and (3) modify the metabolism of residentcells, thus yielding a stroma, which is permissive rather thandefensive.

Beyond overcoming the microenvironmental control by the host, keycharacteristics of cancer cells is their ability to invade the tissueand metastasize distantly. For invasion and metastasis, the concertedinteractions between fibroblasts, immune cells, and angiogenic cells andfactors are essential.

The tumor stroma basically consists of (1) the nonmalignant cells of thetumor such as CAFs, specialized mesenchymal cell types distinctive toeach tissue environment, innate and adaptive immune cells, andvasculature with endothelial cells and pericytes and (2) theextracellular matrix (ECM) consisting of structural proteins (collagenand elastin), specialized proteins (fibrillin, fibronectin, andelastin), and proteoglycans. Angiogenesis is central for cancer cellgrowth and survival and has hitherto been the most successful amongstromal targets in anticancer therapy. Initiation of angiogenesisrequires matrix metalloproteinase (MMP) induction leading to degradationof the basement membrane, sprouting of endothelial cells, and regulationof pericyte attachment. However, CAFs play an important role insynchronizing these events through the expression of numerous ECMmolecules and growth factors, including transforming growth factor(TGF)-β, vascular endothelial growth factor (VEGF), and fibroblastgrowth factor (FGF2).

The normal tissue stroma is essential for maintenance and integrity ofepithelial tissues and contains a multitude of cells that collaborate tosustain normal tissue homeostasis. There is a continuous and bilateralmolecular crosstalk between normal epithelial cells and cells of thestromal compartment, mediated through direct cell-cell contacts or bysecreted molecules. Thus, minor changes in one compartment may causedramatic alterations in the whole system.

A similarity exists between stroma from wounds and tumors, because bothentities had active angiogenesis and numerous proliferating fibroblastssecreting a complex ECM, all on a background of fibrin deposition.Consequently, the tumor stroma has been commonly referred to asactivated or reactive stroma.

A genetic alteration during cancer development, leading to a malignantcell, will consequently change the stromal host compartment to establisha permissive and supportive environment for the cancer cell. Duringearly stages of tumor development and invasion, the basement membrane isdegraded, and the activated stroma, containing fibroblasts, inflammatoryinfiltrates, and newly formed capillaries, comes into direct contactwith the tumor cells. The basement membrane matrix also modifiescytokine interactions between cancer cells and fibroblasts. Thesecancer-induced alterations in the stroma will contribute to cancerinvasion. Animal studies have shown that both wounding and activatedstroma provides oncogenic signals to facilitate tumorigenesis. Althoughnormal stroma in most organs contains a minimal number of fibroblasts inassociation with physiologic ECM, the activated stroma is associatedwith more ECM-producing fibroblasts, enhanced vascularity, and increasedECM production. This formation of a specific tumor stroma type at sitesof active tumor cell invasion is considered an integral part of thetumor invasion and has been termed as tumor stromatogenesis.

The expansion of the tumor stroma with a proliferation of fibroblastsand dense deposition of ECM is termed a desmoplastic reaction. It issecondary to malignant growth and can be separated from alveolarcollapse, which do not show neither activated fibroblasts nor the densecollagen/ECM. Morphologically this is termed desmoplasia and wasinitially conceived as a defense mechanism to prevent tumor growth, butdata have shown that in established tumors, this process, quiteoppositely, participates in several aspects of tumor progression, suchas angiogenesis, migration, invasion, and metastasis. The latter studiesshow that fibroblasts and tumor cells can enhance local tissue growthand cancer progression through secreting ECM and degrading components ofECM within the tumor stroma. This is in part related to the release ofsubstances sequestered in the ECM, such as VEGF, and cleavage ofproducts from ECM proteins as a response to secretion ofcarcinoma-associated MMPs.

Profibrotic growth factors, released by cancer cells, such as TGF-β,platelet-derived growth factor (PDGF), and FGF2 govern the volume andcomposition of the tumor stroma as they are all key mediators offibroblast activation and tissue fibrosis. PDGF and FGF2 playsignificant roles in angiogenesis as well.

In tumors, activated fibroblasts are termed as peritumoral fibroblastsor carcinoma-associated fibroblasts (CAFs). CAFs, like activatedfibroblasts, are highly heterogeneous and believed to derive from thesame sources as activated fibroblasts. The main progenitor seems to bethe locally residing fibroblast, but they may also derive from pericytesand smooth muscle cells from the vasculature, from bone marrow-derivedmesenchymal cells, or by epithelial or endothelial mesenchymaltransition. The term CAF is rather ambiguous because of the variousorigins from which these cells are derived, as is the difference betweenactivated fibroblasts and CAFs. There are increasing evidence forepigenetic and possibly genetic distinctions between CAFs and normalfibroblasts. CAFs can be recognized by their expression of a-smoothmuscle actin, but due to heterogeneity a-smooth muscle actin expressionalone will not identify all CAFs. Hence, other used CAF markers arefibroblast-specific protein 1, fibroblast activation protein (FAP), andPDGF receptor (PDGFR) α/β.

In response to tumor growth, fibroblasts are activated mainly by TGF-β,chemokines such as monocyte chemotactic protein 1, and ECM-degradingagents such as MMPs. Although normal fibroblasts in several in vitrostudies have demonstrated an inhibitory effect on cancer progression,today, there is solid evidence for a cancer-promoting role of CAFs. Inbreast carcinomas, as much as 80% of stromal fibroblasts are consideredto have this activated phenotype (CAFs).

CAFs promote malignant growth, angiogenesis, invasion, and metastasis.The roles of CAFS and their potential as targets for cancer therapy havebeen studied in xenografts models, and evidence from translationalstudies has revealed a prognostic significance of CAFs in severalcarcinoma types.

In the setting of tumor growth, CAFs are activated and highly synthetic,secreting, for example, collagen type I and IV, extra domainA-fibronectin, heparin sulfate proteoglucans, secreted protein acidicand rich in cysteine, tenascin-C, connective tissue growth factors,MMPs, and plasminogen activators. In addition to secreting growthfactors and cytokines, which affect cell motility, CAFs are an importantsource for ECM-degrading proteases such as MMPs that play severalimportant roles in tumorigenesis. Through degradation of ECM, MMPs can,depending on substrate, promote tumor growth, invasion, angiogenesis,recruitment of inflammatory cells, and metastasis. Besides, a number ofproinflammatory cytokines seem to be activated by MMPs.

After injection of B16M melanoma cells in mice, the formation of livermetastases was associated with an early activation of stellate cells(fibroblast-like) in the liver, as these seemed important for creating ametastatic niche and promoting angiogenesis. MMPs have also been linkedto tumor angiogenesis in various in vivo models. CAFs, when coinjectedinto mice, facilitated the invasiveness of otherwise noninvasive cancercells. Furthermore, xenografts containing CAFs apparently grow fasterthan xenografts infused with normal fibroblasts.

At CAF recruitment and accumulation in the tumor stroma, these cellswill actively communicate with cancer cells, epithelial cells,endothelial cells, pericytes, and inflammatory cells through secretionof several growth factors, cytokines, and chemokines. CAFs providepotent oncogenic molecules such as TGF-β and hepatocyte growth factor(HGF).

TGF-β is a pleiotropic growth factor expressed by both cancer andstromal cells. TGF-β is, in the normal and premalignant cells, asuppressor of tumorigenesis, but as cancer cells progress, theantiproliferative effect is lost, and instead, TGF-β promotestumorigenesis by inducing differentiation into an invasive phenotype.TGF-β may also instigate cancer progression through escape fromimmunosurveillance, and increased expression of TGF-β correlate stronglywith the accumulation of fibrotic desmoplastic tissue and cancerprogression. Recently, a small molecule inhibitor of TGF-β receptor typeI was reported to inhibit the production of connective tissue growthfactor by hepatocellular carcinoma (HCC) cells, resulting in reducedstromal component of the HCCs. Inhibition of the TGF-β receptor abortedthe crosstalk between HCCs and CAFs and consequently avoided tumorproliferation, invasion, and metastasis. HGF belongs to the plasminogenfamily and is tethered to ECM in a precursor form. It binds to thehigh-affinity receptor c-met, and overexpression or constant oncogenicc-Met signaling lead to proliferation, invasion, and metastasis.

PDGFs are regulators of fibroblasts and pericytes and play importantroles in tumor progression. It is a chemotactic and growth factor formesenchymal and endothelial cells. It has a limited autocrine role intumor cell replication, but is a potential player, in a paracrinefashion, and in tumor stroma development. It induces the proliferationof activated fibroblasts and possibly recruits CAFs indirectly bystimulation of TGF-β release from macrophages.

A tumor cannot develop without the parallel expansion of a tumor stroma.Although we still do not comprehend the exact mechanisms regulatingfibroblast activation and their accumulation in cancer, the availableevidence points to the possibility that the tumor stroma or CAFs arecandidate targets for cancer treatment.

CAFs and MMPs have been considered two of the key regulators ofepithelial-derived tumors representing potential new targets forintegrative therapies, affecting both the transformed andnon-transformed components of the tumor environment. As commentedearlier, the experience with MMP inhibitors have so far beenunsuccessful. Evidence that CAFs are epigenetically and possibly alsogenetically distinct from normal fibroblasts is beginning to definethese cells as potential targets for anticancer therapy. FAP, expressedin more than 90% of epithelial carcinomas, emerged early as a promisingcandidate for targeting CAFs, and the potential therapeutic benefit ofits inhibition was reviewed recently. In preclinical studies, abrogationof FAP attenuates tumor growth and significantly enhance tumor tissueuptake of anticancer drugs. In a phase I study, where patients withFAP-positive advanced carcinomas (colorectal cancer and NSCLC) weretreated with FAP-antibody, the antibody bound specifically to tumorsites, but no objective responses were observed.

The consistent and repeated findings of cancer cells that readilyundergo invasion and metastasis in response to TGF-β have pointed to theneed of novel anticancer agents targeting the oncogenic activities ofTGF-β. A large number of anti-TGF-β antibodies and TGF-β-receptor Ikinases have been tested preclinically during the past decade. Becauseof the lack of success, targeting of the TGF-β signaling system stillremains elusive. It should be noted that both protumoral and antitumoraleffects have been assigned to TGF-β, and the multifunctional nature ofTGF-β apparently represents the greatest barrier to effectively targetthis ligand, its receptor, or downstream effectors.

As a non-limiting example, an indolinone derivative compound as providedherein (e.g., nintedanib) is specially formulated to permit mist orliquid nebulized, or dry powder inhaled aerosol administration to supplyeffective concentrations or amounts conferring desiredanti-inflammatory, anti-fibrotic or tissue-remodeling benefits, forinstance, to prevent, manage or treat patients with pulmonary fibrosis.

Because different drug products are known to vary in efficacy dependingon the dose, form, concentration and delivery profile, the presentlydisclosed embodiments provide specific formulation and deliveryparameters that produce protection against and treatment for pulmonaryfibrosis associated, by non-limiting example with infection, radiationtherapy, chemotherapy, inhalation of environmental pollutants (e.g.dust, vapors, fumes, and inorganic and organic fibers),hypersensitivities, silicosis, byssinosis, genetic factors andtransplant rejection.

For the applications described herein, liquid nebulized or dry powderaerosol nintedanib or indolinone or salt thereof,) may beco-administered, administered sequentially or prepared in a fixedcombination with an antimicrobial (e.g. tobramycin and/or otheraminoglycoside such as amikacin, aztreonam and/or other beta ormono-bactam, ciprofloxacin, levofloxacin and/or other, fluoroquinolones,azithromycin and/or other macrolides or ketolides, tetracycline and/orother tetracyclines, quinupristin and/or other streptogramins, linezolidand/or other oxazolidinones, vancomycin and/or other glycopeptides, andchloramphenicol and/or other phenicols, and colistin and/or otherpolymyxins), bronchodilator (e.g. beta-2 agonists and muscarinicantagonists), corticosteroids (e.g. salmeterol, fluticasone andbudesonide), glucocorticoids (e.g. prednisone), Cromolyn, Nedocromil,Leukotriene modifiers (e.g. montelukast, zafirlukast and zileuton)hyperosmolar solution, DNAse or other mucus thinning agent, interferongamma, cyclophosphamide, colchicine, N-acetylcysteine, azathioprine,bromhexine, endothelin receptor antagonist (e.g. bosentan andambrisentan), PDE5 inhibitor (e.g. sildenafil, vardenafil andtadalafil), PDE4 inhibitor (e.g. roflumilast, cilomilast, oglemilast,tetomilast and SB256066), prostinoid (e.g. epoprostenol, iloprost andtreprostinin), nitric oxide or nitric oxide-donating compound, IL-13blocker, IL-10 blocker, CTGF-specific antibody, CCN2 inhibitors,angiotensin-converting enzyme inhibitors, angiotensin receptorantagonists, PDGF inhibitors, PPAR antagonist, oral nintedanib,CCL2-specific antibody, CXCR2 antogonist, triple growth factor kinaseinhibitor, anticoagulant, TNF blocker, tetracycline or tetracyclinederivative, 5-lipoxygenase inhibitor, pituitary hormone inhibitor,TGF-beta-neutralizing antibody, copper chelator, angiotensin II receptorantagonist, chemokine inhibitor, NF-kappaB inhibitor, NF-kappaBantisense oligonucleotide, IKK-1 and -2 inhibitor (e.g.imidazoquinoxaline or derivative, and quinazoline or derivative), JNK2and/or p38 MAPK inhibitor (e.g. pyridylimidazolbutyn-I-ol, SB856553,SB681323, diaryl urea or derivative, and indole-5-carboxamide), PI3Kinhibitor, LTB4 inhibitor, antioxidant (e.g.Mn-pentaazatetracyclohexacosatriene, M40419, N-acetyl-L-cysteine,Mucomyst, Fluimucil, Nacystelyn, Erdosteine, Ebeselen, thioredoxin,glutathione peroxidase memetrics, Curcumin C3 complex, Resveratrol andanalogs, Tempol, catalytic antioxidants, and OxSODrol), TNF scavenger(e.g. infliximab, ethercept, adalumimab, PEG-sTNFR 1, afelimomab, andantisense TNF-alpha oligonucleotide), Interferon beta-1a (Avonex,Betaseron, or Rebif), glatiramer acetate (Copaxone), mitoxantrone(Novantrone), natalizumab (Tysabri), Methotrexate, azathioprine(Imuran), intravenous immunoglobulin (IVIg), cyclophosphamide (Cytoxan),lioresal (Baclofen), tizanidine (Zanaflex), benzodiazepine, cholinergicmedications, antidepressants and amantadine.

As shown as a promising approach to treat cancer and pulmonary arterialhypertension, to enable “cocktail therapy” or “cocktail prophylaxis” infibrotic disease, more specifically idiopathic pulmonary fibrosis andother pulmonary fibrotic disease, methods to administer inhalednintedanib or indolinone or salt thereof, are co-administered,administered sequentially, or co-prescribed (such that medicines arerequested by a prescribing physician to be taken in some sequence ascombination therapy to treat the same disease) with agents targetingcancer, fibrotic or inflammatory disease. By non-limiting example,nintedanib or indolinone or salt thereof, are administered either infixed combination, co-administered, administered sequentially, orco-prescribed with the monoclonal GS-6624 (formerly known as AB0024),analog or another antibody targeting LOXL2 protein associated withconnective tissue biogenesis to reduce inflammation, tumor stroma and/orfibrosis. By another non-limiting example, nintedanib or indolinone orsalt thereof, are administered either in fixed combination,co-administered, administered sequentially, or co-prescribed with IW001(Type V collagen), analog or other collagen targeting immunogenictolerance to reduce inflammation, tumor stroma and/or fibrosis. Byanother non-limiting example, nintedanib or indolinone or salt thereof,are administered either in fixed combination, co-administered,administered sequentially, or co-prescribed with PRM-151 (recombinantpentraxin-2), CC-930 (Jun kinase inhibitor), analog or other Jun kinaseinhibitor to reduce the inflammation, tumor stroma and/or fibrosis, oralimatinib (a.k.a. Gleeve or Glivec (tyrosine kinase inhibitor)), analogor other tyrosine to inhibit lung fibroblast-myofibroblasttransformation and proliferation as well as extracellular matrixproduction and tumor stroma formation/maintenance through inhibition ofPDFG and transforming growth factor (TGF)-β signaling, STX-100(monoclonal antibody targeting integrin alpha-v beta-6), analog or otherantibody targeting integrin alpha-v beta-6 or other integrin to reduceinflammation, tumor stroma and/or fibrosis, QAX576 (monoclonal antibodytargeting interleukin 13 [IL-13]), analog or other antibody targetingIL-13 to reduce inflammation, tumor stroma and/or fibrosis, FG-3019(monoclonal antibody targeting connective tissue growth factor [CTGF]),analog or other antibody targeting CTGF to reduce inflammation, tumorstroma and/or fibrosis, CNTO-888 (a monoclonal antibody targetingchemokine [C-C motif] ligand 2 [CCL2]), analog or other antibodytargeting CCL2 to reduce inflammation, tumor stroma and/or fibrosis,Esbriet®, Pirespa® or Pirfenex® (trade names for pirfenidone), or analogtargeting inflammation, tumor stroma and/or fibrosis, SM-04646 (inhaledWNT/MET inhibitor), analog or other chemical targeting WNT/MET to reduceinflammation, tumor stroma and/or fibrosis, N-acetylcysteine (NAC;anti-oxidant), analog or other chemical targeting oxidation to reduceinflammation, tumor stroma and/or fibrosis, PRM-151 (intravenousrecombinant human pentraxin-3; macrophage signal modulator), analog orother chemical targeting macrophage to reduce inflammation, tumor stromaand/or fibrosis, MK-2 (inhaled MK-2 inhibitor), analog or other chemicaltargeting MK-2 to reduce inflammation, tumor stroma and/or fibrosis,CC-90001 (oral JNK1 inhibitor), analog or other chemical targeting JNK1to reduce inflammation, tumor stroma and/or fibrosis, GLPG-1690 (oralautotaxin inhibitor), analog or other chemical targeting autotaxin toreduce inflammation, tumor stroma and/or fibrosis, BI1015550 to reduceinflammation, tumor stroma and/or fibrosis, Gefapixant (oral coughinhibitor), analog or other chemical targeting cough to reduceinflammation, tumor stroma and/or fibrosis, cromalin (inhaled coughinhibitor), analog or other chemical targeting cough to reduceinflammation, tumor stroma and/or fibrosis, PBI-4050 (oral endoplasmicreticulum stress (ER stress) inhibitor), analog or other chemicaltargeting ER stress to reduce inflammation, tumor stroma and/orfibrosis, TD-139 (inhaled galectin-3 inhibitor), analog or otherchemical targeting galectin-3 to reduce inflammation, tumor stromaand/or fibrosis, tipelukast (oral leukotriene and PDE inhibitor), analogor other chemical targeting leukotriene and/or PDE to reduceinflammation, tumor stroma and/or fibrosis, or PAT-1251 (oral LoxL2inhibitor), analog or other chemical targeting LoxL2 to reduceinflammation, tumor stroma and/or fibrosis, and combinations thereof.

As with administration of nintedanib or indolinone and their salts, oraland parenteral routes of administration (by non-limiting example,intravenous and subcutaneous) of other compounds, molecules andantibodies targeting the reduction of inflammation, tumor stroma and/orfibrosis is often associated with, by non-limiting example, adversereactions such as gastrointestinal side effects, liver, kidney, skin,cardiovascular or other toxicities. As described herein the benefits oforal or intranasal inhalation directly to the lung or tissuesimmediately downstream of the nasal and/or pulmonary compartments willalso benefit these compounds by avoiding direct delivery to thegastrointestinal tract and/or reducing systemic exposure therebyreducing gastrointestinal symptoms generated in the central nervoussystem. Therefore, by non-limiting example, the monoclonal GS-6624(formerly known as AB0024), analog or another antibody targeting LOXL2protein associated with connective tissue biogenesis to reduceinflammation, tumor stroma and/or fibrosis may be administered by oralor intranasal inhalation for direct delivery to the lung or tissuesimmediately downstream of the nasal or pulmonary compartments. Byanother non-limiting example, PRM-151 (recombinant pentraxin-2), analogor other molecule targeting regulation of the injury response to reduceinflammation and/or fibrosis may be administered by oral or intranasalinhalation for direct delivery to the lung or tissues immediatelydownstream of the nasal or pulmonary compartments, CC-930 (Jun kinaseinhibitor), analog or other Jun kinase inhibitor to reduce tumor stromaand/or the inflammatory response may be administered by oral orintranasal inhalation for direct delivery to the lung or tissuesimmediately downstream of the nasal or pulmonary compartments, oralimatinib (a.k.a. Gleeve or Glivec (tyrosine kinase inhibitor)),transforming growth factor (TGF)-β signaling may be administered by oralor intranasal inhalation for direct delivery to the lung or tissuesimmediately downstream of the nasal or pulmonary compartments, STX-100(monoclonal antibody targeting integrin alpha-v beta-6), analog or otherantibody targeting integrin alpha-v beta-6 or other integrin to reducetumor stroma and/or fibrosis, QAX576 (monoclonal antibody targetinginterleukin 13 [IL-13]), analog or other antibody targeting IL-13 toreduce tumor stroma and/or inflammation, may be administered by oral orintranasal inhalation for direct delivery to the lung or tissuesimmediately downstream of the nasal or pulmonary compartments, FG-3019(monoclonal antibody targeting connective tissue growth factor [CTGF]),analog or other antibody targeting CTGF to reduce tumor stroma and/orfibrosis may be administered by oral or intranasal inhalation for directdelivery to the lung or tissues immediately downstream of the nasal orpulmonary compartments, CNTO-888 (a monoclonal antibody targetingchemokine [C-C motif] ligand 2 [CCL2]), analog or other antibodytargeting CCL2 to reduce tumor stroma and/or fibrosis, SM-04646 (inhaledWNT/MET inhibitor), analog or other chemical targeting WNT/MET to reducetumor stroma and/or fibrosis and/or inflammation, N-acetylcysteine (NAC;anti-oxidant), analog or other chemical targeting oxidation to reducetumor stroma and/or fibrosis and/or inflammation, PRM-151 (intravenousrecombinant human pentraxin-3; macrophage signal modulator), analog orother chemical targeting macrophage to reduce tumor stroma and/orfibrosis and/or inflammation, MK-2 (inhaled MK-2 inhibitor), analog orother chemical targeting MK-2 to reduce tumor stroma and/or fibrosisand/or inflammation, CC-90001 (oral JNK1 inhibitor), analog or otherchemical targeting JNK1 to reduce tumor stroma and/or fibrosis and/orinflammation, GLPG-1690 (oral autotaxin inhibitor), analog or otherchemical targeting autotaxin to reduce tumor stroma and/or fibrosisand/or inflammation, BI1015550 to reduce tumor stroma and/or fibrosisand/or inflammation, Gefapixant (oral cough inhibitor), analog or otherchemical targeting cough to reduce tumor stroma and/or fibrosis and/orinflammation, PBI-4050 (oral endoplasmic reticulum stress (ER stress)inhibitor), analog or other chemical targeting ER stress to reduce tumorstroma and/or fibrosis and/or inflammation, TD-139 (inhaled galectin-3inhibitor), analog or other chemical targeting galectin-3 to reducetumor stroma and/or fibrosis and/or inflammation, tipelukast (oralleukotriene and PDE inhibitor), analog or other chemical targetingleukotriene and/or PDE to reduce tumor stroma and/or fibrosis and/orinflammation, PAT-1251 (oral LoxL2 inhibitor), analog or other chemicaltargeting LoxL2 to reduce tumor stroma and/or fibrosis and/orinflammation, and combinations thereof.

A promising approach to treat cancer and pulmonary arterial hypertensionis the administration of “cocktail therapy” or “cocktail prophylaxis”where the method is comprised of co-administering or sequentiallyadministering inhaled nintedanib or indolinone or salt thereof withagents targeting cancer, including but not limited to gefitinib (Iressa,also known as ZD1839), Erlotinib (also known as Tarceva), Bortezomib(originally codenamed PS-341; marketed as Velcade®and Bortecad®), Januskinase inhibitors, ALK inhibitors, PARP inhibitors (Iniparib; BSI 201);PI3K inhibitors, Apatinib (YN968D1), Selumetinib, Salinomycin,Abitrexate (methotrexate), Abraxane (Paclitaxel Albumin-stabilizedNanoparticle Formulation), Afatinib Dimaleate, Alimta (pemetrexeddisodium), Avastin (Bevacizumab), Carboplatin, Cisplatin, Crizotinib,Erlotinib Hydrochloride, Folex (methotrexate), Folex PFS (methotrexate),Gefitinib Gilotrif (afatinib dimaleate), Gemcitabine Hydrochloride,Gemzar (gemcitabine hydrochloride), Iressa (Gefitinib), Methotrexate,Methotrexate LPF (methotrexate), Mexate (methotrexate), Mexate-AQ(methotrexate), Paclitaxel, Paclitaxel Albumin-stabilized NanoparticleFormulation, Paraplat (carboplatin), Paraplatin (carboplatin),Pemetrexed Disodium, Platinol (cisplatin), Platinol-AQ (Cisplatin),Tarceva (Erlotinib Hydrochloride), Taxol (Paclitaxel), and Xalkori(Crizotinib).

Combinations approved for non-small cell lung cancer may include:Carboplatin-Taxol and Gemcitabline-Cisplatin.

Drugs approved for small cell lung cancer may include: Abitrexate(methotrexate), Etopophos (etoposide phosphate), Etoposide, EtoposidePhosphate, Folex (methotrexate), Folex PFS (methotrexate), Hycamtin(topotecan hydrochloride), Methotrexate, Methotrexate LPF(methotrexate), Mexate (methotrexate), Mexate-AQ (methotrexate), Toposar(etoposide), Topotecan Hydrochloride, and VePesid (etoposide).

Pharmaceutical Formulation and Packaging

Selection of a particular nintedanib composition or indolinone or saltthereof, is accompanied by the selection of a specially designed productpackaging and configuration that maximizes the therapeutic utility ofthe particular composition. Factors to be considered in selectingpackaging may include, for example, intrinsic product stability, whetherthe formulation may be subject to lyophilization, device selection(e.g., liquid nebulizer, dry-powder inhaler, meter-dose inhaler), and/orpackaging form (e.g., simple liquid or complex liquid formulation,whether provided in a vial as a liquid or as a lyophilisate to bedissolved prior to or upon insertion into the device; complex suspensionformulation whether provided in a vial as a liquid or as a lyophilisate,and with or without a soluble salt/excipient component to be dissolvedprior to or upon insertion into the device, or separate packaging ofliquid and solid components; dry powder formulations in a vial, capsuleor blister pack; and other formulations packaged as readily soluble orlow-solubility solid agents in separate containers alone or togetherwith readily soluble or low-solubility solid agents.

In one preferred embodiment, the compositions will take the form of aunit dosage form such as vial containing a liquid, solid to besuspended, dry powder, lyophilisate, or other composition and thus thecomposition may contain, along with the active ingredient, a diluentsuch as lactose, sucrose, dicalcium phosphate, or the like; a lubricantsuch as magnesium stearate or the like; and a binder such as starch, gumacacia, polyvinylpyrrolidine, gelatin, cellulose, cellulose derivativesor the like.

Liquid pharmaceutically compositions can, for example, be prepared bydissolving, dispersing, etc. an active compound and optionalpharmaceutical adjuvants in a carrier (e.g., water, saline, aqueousdextrose, glycerol, glycols, ethanol or the like). Solutions to beaerosolized can be prepared in conventional forms, either as liquidsolutions or suspensions, or in solid forms suitable for dissolution orsuspension in liquid prior to aerosol production and inhalation. Thepercentage of active compound contained in such aerosol compositions ishighly dependent on the specific nature thereof, as well as the activityof the compound and the needs of the subject. Typically, 0.25%-50.0% ofthe active agent in an aqueous solution is acceptable foraerosolization.

Nintedanib or indolinone or salt thereof compound formulations can beseparated into two groups; those of simple formulation or complexformulations providing taste-masking for improved tolerability,pH-optimized for stability and tolerability, immediate orsustained-release, and/or area-under-the-curve (AUC) shape-enhancingproperties. Simple formulations can be further separated into threegroups. 1. Simple formulations may include water-based liquidformulations for nebulization. Water-based liquid formulations includenintedanib or indolinone active ingredient with non-encapsulating watersoluble excipients 2) additional organic-based liquid formulations fornebulization or meter-dose inhaler with nintedanib or indolinonenon-encapsulating organic soluble excipients; 3) dry powder formulationsfor administration with a dry powder inhaler nintedanib or indolinonealone or with either water soluble or organic soluble non-encapsulatingexcipients with or without a carrier agent such as lactose.

Complex formulations containing active ingredient can be furtherseparated into five groups: 1) nintedanib or indolinone formulationswith active ingredient encapsulated or complexed with water-solubleexcipients such as lipids, liposomes, cyclodextrins,microencapsulations, and emulsions; 2) organic-based liquid formulationsfor nebulization or meter-dose inhaler with active ingredient nintedanibor indolinone encapsulated or complexed with organic-soluble excipientssuch as lipids, microencapsulations, and reverse-phase water-basedemulsions; 3) formulations including low-solubility, water-based liquidformulations for nebulization comprised of nintedanib or indolinone,stable nanosuspension alone or in co-crystal/co-precipitate excipientcomplexes, or mixtures with low solubility lipids, such as lipidnanosuspensions; 4) low-solubility, organic-based liquid formulationsfor nebulization or meter-dose inhaler nintedanib or indolinone as alow-organic soluble, stable nanosuspension alone or inco-crystal/co-precipitate excipient complexes, or mixtures with lowsolubility lipids, such as lipid nanosuspensions; and 5) dry powderformulations for administration using a dry powder inhaler of nintedanibor indolinone as a co-crystal/co-precipitate/spray dried complex ormixture with low-water soluble excipients/salts in dry powder form withor without a carrier agent such as lactose. Specific methods for simpleand complex formulation preparation are described herein.

The aerosol for delivery to the lungs of a human contains a fineparticle fraction between 10 and 100% with increment units of 1%. Byexample, about 10%, about 15%, about 20%, about 25%, about 30%, about35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%,about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, andabout 100%. The fine particle dose is between about 0.0001 mg to about100 mg nintedanib or salt thereof. By example, about 0.0001 mg, about0.001 mg, about 0.005 mg, about 0.01 mg, and about 0.05 mg in 0.01 mgincrements. By further example, about 2 mg, about 3 mg, about 4 mg,about 5 mg, about 6 mg, about 7 mg, about 8 mg, about 9 mg, about 10 mg,about 11 mg, about 12 mg, about 13 mg, about 14 mg, about 15 mg, about16 mg, about 17 mg, about 18 mg, about 19 mg, about 20 mg, about 25 mg,about 30 mg, about 35 mg, about 40 mg, about 45 mg, about 50 mg, about60 mg, about 70 mg, about 80 mg, about 90 mg, about 100 mg, about 120mg, about 140 mg, about 160 mg, about 180 mg, about 200 mg in 0.1 mgincrements. By example, about 0.001 mg, about 0.005 mg, about 0.01 mg,about 0.05 mg, about 0.1 mg, and about 0.5 mg, about 1 mg, about 5 mg,about 10 mg, about, about 20 mg, about 30 mg, about 40 mg, about 50 mg,about 100 mg, about 200 mg in 0.01 mg increments.

In some embodiments, nintedanib or indolinone or salt thereof, has aosmolality adjusting agent suitable for pulmonary delivery. Theosmolality adjusting agent includes a co-solvent selected from propyleneglycol, ethanol, polyethylene glycol 400, mannitol and glycerin. Thecompositions further comprise a second anti-fibrotic or anti-cancer oranti-infective or anti-infective agent suitable for pulmonary delivery.The compositions further comprise a second anti-inflammatory agentsuitable for pulmonary delivery. The composition may be co-administeredwith a second anti-fibrotic or anti-cancer or anti-infective agentsuitable for pulmonary delivery. The composition co-administered asecond anti-inflammatory agent suitable for pulmonary delivery.

In another embodiment, a pharmaceutical composition is provided thatincludes a simple or complex liquid nintedanib or indolinone saltthereof with non-encapsulating water-soluble excipients as describedabove having an osmolality from about 50 mOsmol/kg to about 600mOsmol/kg. In other embodiments the osmolality is from about 50, 100,150, 200, 250, 300, 350, 400, 450, 500 mOsmol/kg to about 1000, 1100,1200, 1300, 1400, 1500, 1600, 1700, 1800, 1900, 2000 mOsmol/kg andpreferably between about 50 mOsmol/kg and about 600 mosmol/kg.

The simple or complex formulation preferably has nintedanib orindolinone a permeant ion concentration between from about 30 mM toabout 150 mM. The permeant ions in the composition are preferablyselected from the group consisting of chloride and bromide andcombinations thereof.

Nintedanib or indolinone nintedanib or indolinone In another embodiment,a pharmaceutical composition is provided that includes a simple orcomplex liquid nintedanib or indolinone or salt thereof compoundformulation as a low water-soluble stable nanosuspension alone or inco-crystal/co-precipitate complexes, or mixtures with low solubilitylipids, such as lipid nanosuspensions) as described above having asolution osmolality from about 50 mOsmol/kg to about 600 mOsmol/kg. Inone embodiment, the osmolality is from about 100 mOsmol/kg to about 500mOsmol/kg.

In another embodiment, a pharmaceutical composition is provided thatincludes a complex suspension of a nintedanib or indolinone or saltthereof compound formulation having a permeant ion concentration fromabout 30 mM to about 150 mM. In one such embodiment, one or morepermeant ions in the composition are selected from the group consistingof chloride and bromide.

In another embodiment, a pharmaceutical composition is provided thatincludes a complex suspension of a nintedanib or indolinone or saltthereof compound formulation having a permeant ion concentration fromabout 30 mM to about 150 mM. In one such embodiment, one or morepermeant ions in the composition are selected from the group consistingof chloride and bromide.

In other embodiments, nintedanib or indolinone or includes ataste-masking agent including sugar, saccharin (e.g., sodium saccharin),sweetener or other compound or agent that beneficially affects taste,after-taste, perceived unpleasant saltiness, sourness or bitterness, orthat reduces the tendency of an oral or inhaled formulation to irritatea recipient (e.g., by causing coughing or sore throat or other undesiredside effect, such as may reduce the delivered dose or adverselyinfluence patient compliance with a prescribed therapeutic regimen).Certain taste-masking agents may form complexes with the nintedanib orindolinone or salt thereof.

In another embodiment, a salt form of nintedanib or indolinonecounterion of the salt form of nintedanib or indolinone is acetate,acetonide, alanine, aluminum, arginine, ascorbate, asparagine, asparticacid, benzathine, benzoate, besylate, bisulfate, bisulfite, bitartrate,bromide (including bromide and hydrobromide), calcium, carbonate,camphorsulfonate, cetylpridinium, chloride (including chloride andhydrochloride), chlortheophyllinate, cholinate, cysteine, deoxycholate,diethanolamine, diethylamine, diphosphate, diproprionate, disalicylate,edetate, edisylate, estolate, ethylamine, ethylenediamine,ethandisulfonate, esylate, esylate hydroxide, gluceptate, gluconate,glucuronate, glutamic acid, glutamine, glycine, hippurate, histidine,hydrobromide, hydrochloride, hydroxide, iodide, isethionate, isoleucine,lactate, lactobionate, laurylsulfate, leucine, lysine, magnesium,mandelate, meglumine, mesylate, metabisulfate, metabisulfite,methionine, methylbromide, methylsulfate, methyl p-hydroxybenzoate,mucate, naphthoate, napsylate, nitrate, nitrite, octadecanoate, oleate,ornithine, oxalate, pamoate, pentetate, phenylalanine, phosphate,piperazine, polygalacturonate, potassium, procaine, proline, propionate,propyl p-hydroxybenzoate, saccharin, salicylate, selenocysteine, serine,silver, sodium, sorbitan, stearate, succinate, sulfate, sulfite,sulfosalicylate, tartrate, threonine, tosylate, triethylamine,triethiodide, trifluoroacetate, trioleate, tromethamine, tryptophan,tyrosine, valerate, valine, xinafoate, or zinc. Included in the abovepharmaceutical composition is the maintenance of the buffers describedherein, at a pH from about 3.0 to about 7.0, preferably from about pH3.0 to about pH 6.0, and may include an additional salt form at a levelthat provides an osmolality of 50 mOsmo/kg and 600 mOsmo/kg. While 300mOsmo/kg is discussed in the literature as important for acutetolerability upon inhalation of this in a nebulized solution, 600mOsmo/kg has been shown in unpublished studies to be well tolerated withother drug solutions.

The counterion of the salt form of nintedanib, a indolinone derivativeserves as a permeant ion. By non-limiting example, a chloride salt ofnintedanib or indolinone derivative may serve or contribute to thepharmaceutical composition permeant ion. By non-limiting example, abromide salt of nintedanib or indolinone derivative may serve orcontribute to the pharmaceutical composition permeant ion. While thenintedanib or indolinone derivative counterion may contribute topermeant ion, additional permeant ion may be added. By non-limitingexample, nintedanib or indolinone derivative counterion permeant ion maybe supplemented with additional sodium chloride or additional sodiumbromide or combinations of chloride and bromide to achieve between about30 mM to about 150 mM permeant ion. For tolerability, additional solutemay be added to the pharmaceutical composition. By non-limiting example,osmolality by be adjusted to within about 50 mOsmo/kg to about 2000mOsmo/kg by addition of sodium chloride, magnesium chloride or calciumchloride. By non-limiting example, osmolality by be adjusted to withinabout 50 mOsmo/kg to about 1000 mOsmo/kg by addition of sodium bromide,magnesium bromide or calcium bromide. By non-limiting example,osmolality by be adjusted to within about 50 mOsmo/kg to about 1000mOsmo/kg by addition of osmolality adjusting agents. By non-limitingexample, osmolality adjusting agents include co-solvents selected fromethanol, cetylpridinium chloride, mannitol glycerin, lecithin, propyleneglycol, polysorbate (including polysorbate 20, 40, 60, 80 and 85) andsorbitan triolate.

The nintedanib salt form or indolinone salt form is prepared as achloride or bromide salt form.

In some embodiments, nintedanib drug product includes nintedanib at aconcentration of about 0.01 mg/mL to about 10 mg/mL in water, optionallya buffer (by non-limiting example lysinate, acetylcysteine, glycine,glutamate, borate, succinate, tartrate, phosphate or Tris, optionally aninorganic salts (by non-limiting example sodium chloride, magnesiumchloride, calcium chloride, sodium bromide, magnesium bromide, and/orcalcium bromide), and optionally a osmolality adjusting agent includingco-solvent(s) (by non-limiting example ethanol, propylene glycol,mannitol and glycerin), optionally a surfactant(s) (by non-limitingexample Tween 80, Tween 60, lecithin, Cetylpyridinium, and Tween 20), ata pH of about 3.0 to about 7.0, preferably from about pH 3.0 to about pH6.0. The formulation also includes a taste-masking agent (bynon-limiting example sodium saccharin). The pharmaceutical compositionincludes at least about 0.0001 mg to about 100 mg, including allintegral values therein such as 0.0001, 0.00025, 0.0005, 0.001, 0.005,0.01, 0.05, 0.1, 0.5, 1.0, 1.5, 2.0, 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5,6.0, 6.5, 7.0, 7.5, 7.0, 8.5, 9.0, 9.5, 10.0, 15, 20, 30, 40, 50, 100milligrams. The osmolality of the pharmaceutical composition describedherein is between about 50 mOsmo/kg to 600 mOsmo/kg.

In one aspect, provided herein is a kit comprising: a pharmaceuticalcomposition comprising an nintedanib or indolinone or salt thereof isformed in a sealed, sterile container, wherein the solution has annintedanib or indolinone or salt thereof has a concentration greaterthan about 0.0001 mg/mL, an osmolality greater than about 100 mOsmol/kg,and a pH greater than about 3.0. The nintedanib or salt thereof orindolinone salt thereof concentration is greater than about 0.01 mg/mL.The nintedanib or salt thereof or indolinone, or salt thereofconcentration is greater than about 0.025 mg/mL. The nintedanib orindolinone or salt thereof concentration is greater than about 0.05mg/mL. The nintedanib or indolinone or concentration is greater thanabout 0.1 mg/mL. The nintedanib or indolinone or concentration isgreater than about 0.25 mg/mL. The nintedanib or indolinone orconcentration is greater than about 0.5 mg/mL. The nintedanib orindolinone or concentration is greater than about 0.75 mg/mL. Thenintedanib or indolinone or concentration is greater than about 1.0mg/mL. The nintedanib or indolinone or concentration is greater thanabout 1.5 mg/mL. The nintedanib or indolinone or salt thereof is greaterthan about 2.0 mg/mL. The nintedanib or indolinone or salt thereofconcentration is greater than about 2.5 mg/mL. The nintedanib orindolinone or salt thereof concentration is greater than about 5.0mg/mL. The nintedanib or salt thereof or indolinone saltsolution has apermeant ion concentration from about 30 mM to about 150 mM. Thepermeant ion is chloride or bromide. The nintedanib or indolinonenintedanib or indolinone or salt thereof solution has a pH from about3.0 to about 7.0, preferably from about pH 3.0 to about pH 6.0. Thenintedanib or indolinone nintedanib or indolinone or salt thereofsolution has an osmolality from about 50 mOsmol/kg to about 600mOsmol/kg. The nintedanib or indolinone nintedanib or indolinone or saltthereof solution has a taste masking agent selected from the groupconsisting of lactose, sucrose, dextrose, saccharin, aspartame,sucrulose, ascorbate and citrate and combinations thereof. In someembodiments, nintedanib or indolinone or salt thereof, solution has aosmolality adjusting agents suitable for pulmonary delivery. Theosmolality adjusting agents includes co-solvents selected from propyleneglycol, ethanol, polyethylene glycol 400, and glycerin. The kit furthercomprises a second anti-fibrotic or anti-cancer or anti-infective agentsuitable for pulmonary delivery. The kit further comprises a secondanti-inflammatory agent suitable for pulmonary delivery. The compositionmay be co-administered with a second anti-fibrotic or anti-cancer oranti-infective agent suitable for pulmonary delivery. The compositionco-administered a second anti-inflammatory agent suitable for pulmonarydelivery.

In one aspect, provided herein is a kit comprising: two containers whereupon admixture create a pharmaceutical composition comprising annintedanib or indolinone or salt thereof solution in a sterilecontainer, wherein the solution has an nintedanib or indolinone or saltthereof concentration greater than about 0.0001 mg/mL, having anosmolality greater than about 50 mOsmol/kg, and having a pH greater thanabout 3.0. The nintedanib or indolinone or salt thereof concentration isgreater than about 0.01 mg/mL. The nintedanib or indolinone or saltthereof concentration is greater than about 0.025 mg/mL. The nintedanibor indolinone or salt thereof concentration is greater than about 0.05mg/mL. The nintedanib or indolinone or salt thereof concentration isgreater than about 0.1 mg/mL. The nintedanib or indolinone or saltthereof concentration is greater than about 0.25 mg/mL. The nintedanibor indolinone or salt thereof concentration is greater than about 0.5mg/mL. The nintedanib or indolinone or salt thereof concentration isgreater than about 0.75 mg/mL. The nintedanib or indolinone or saltthereof concentration is greater than about 1.0 mg/mL. The nintedanib orindolinone or salt thereof concentration is greater than about 1.5mg/mL. The nintedanib or indolinone or salt thereof concentration isgreater than about 2.0 mg/mL. The nintedanib or indolinone or saltthereof concentration is greater than about 2.5 mg/mL. The nintedanib orindolinone or salt thereof concentration is greater than about 5.0mg/mL.

In one aspect, provided herein is a kit comprising: a unit dose whereina pharmaceutical composition comprising an nintedanib or indolinone orsalt thereof and pirfenidone or pyridone analog solution in a sterilecontainer, wherein the solution has an nintedanib or indolinone or saltthereof concentration greater than about 0.0001 mg/mL and a pirfenidoneor pyridone analog concentration greater than about 5 mg/mL, having anosmolality greater than about 50 mOsmol/kg, and having a pH greater thanabout 3.0. The nintedanib or indolinone or salt thereof concentration isgreater than about 0.01 mg/mL. The nintedanib or indolinone or saltthereof concentration is greater than about 0.025 mg/mL. The nintedanibor indolinone or salt thereof concentration is greater than about 0.05mg/mL. The nintedanib or indolinone or salt thereof concentration isgreater than about 0.1 mg/mL. The nintedanib or indolinone or saltthereof concentration is greater than about 0.25 mg/mL. The nintedanibor indolinone or salt thereof concentration is greater than about 0.5mg/mL. The nintedanib or indolinone or salt thereof concentration isgreater than about 0.75 mg/mL. The nintedanib or indolinone or saltthereof concentration is greater than about 1.0 mg/mL. The nintedanib orindolinone or salt thereof concentration is greater than about 1.5mg/mL. The nintedanib or indolinone or salt thereof concentration isgreater than about 2.0 mg/mL. The nintedanib or indolinone or saltthereof concentration is greater than about 2.5 mg/mL. The nintedanib orindolinone or salt thereof concentration is greater than about 5.0mg/mL. The nintedanib or indolinone or salt thereof concentration isgreater than about 10.0 mg/mL. The nintedanib or indolinone or saltthereof concentration is greater than about 15.0 mg/mL. The nintedanibor indolinone or salt thereof concentration is greater than about 20.0mg/mL. The nintedanib or indolinone or salt thereof concentration isgreater than about 25.0 mg/mL. The nintedanib or indolinone or saltthereof concentration is greater than about 30.0 mg/mL. The nintedanibor indolinone or salt thereof concentration is greater than about 35.0mg/mL. The nintedanib or indolinone or salt thereof concentration isgreater than about 40.0 mg/mL. The nintedanib or indolinone or saltthereof concentration is greater than about 45.0 mg/mL. The nintedanibor indolinone or salt thereof concentration is greater than about 50.0mg/mL. The pirfenidone or pyridone analog concentration is greater thanabout 5 mg/mL. The pirfenidone or pyridone analog concentration isgreater than about 6 mg/mL. The pirfenidone or pyridone analogconcentration is greater than about 7 mg/mL. The pirfenidone or pyridoneanalog concentration is greater than about 8 mg/mL. The pirfenidone orpyridone analog concentration is greater than about 9 mg/mL. Thepirfenidone or pyridone analog concentration is greater than about 10mg/mL. The pirfenidone or pyridone analog concentration is greater thanabout 11 mg/mL. The pirfenidone or pyridone analog concentration isgreater than about 12 mg/mL. The pirfenidone or pyridone analogconcentration is greater than about 13 mg/mL. The pirfenidone orpyridone analog concentration is greater than about 14 mg/mL. Thepirfenidone or pyridone analog concentration is greater than about 15mg/mL. The pirfenidone or pyridone analog concentration is greater thanabout 16 mg/mL. The pirfenidone or pyridone analog concentration isgreater than about 17 mg/mL. The pirfenidone or pyridone analogconcentration is greater than about 18 mg/mL. The pirfenidone orpyridone analog concentration is greater than about 19 mg/mL. Thepirfenidone or pyridone analog concentration is greater than about 20mg/mL.

The nintedanib or indolinone or salt thereof solution has a permeant ionconcentration from about 30 mM to about 150 mM. The permeant ion ischloride or bromide. The nintedanib or indolinone or salt thereofsolution has a pH from about 3.0 to about 7.0, preferably from about pH3.0 to about pH 6.0. The nintedanib or indolinone or salt thereofsolution has an osmolality from about 50 mOsmol/kg to about 600mOsmol/kg. The nintedanib or indolinone or salt thereof solution has ataste masking agent. The taste masking agent is selected from the groupconsisting of lactose, sucrose, dextrose, saccharin, aspartame,sucrulose, and ascorbate. In some embodiments, nintedanib or indolinoneor salt thereof, solution has a osmolality adjusting agents suitable forpulmonary delivery, including co-solvents selected from the groupconsisting of propylene glycol, ethanol, polyethylene glycol 400, andglycerin and combinations thereof. The solution further comprises asecond anti-fibrotic or anti-cancer or anti-infective agent suitable forpulmonary delivery. The kit further comprises a second anti-inflammatoryagent suitable for pulmonary delivery. The composition may beco-administered with a second anti-fibrotic or anti-cancer oranti-infective agent suitable for pulmonary delivery. The compositionco-administered a second anti-inflammatory agent suitable for pulmonarydelivery.

The nintedanib or indolinone or salt thereof and pirfenidone or pyridoneanalog solution has a permeant ion concentration from about 30 mM toabout 500 mM. The permeant ion is chloride or bromide. The nintedanib orindolinone or salt thereof solution has a pH from about 3.0 to about7.0, preferably from about pH 3.0 to about pH 6.0. The nintedanib orindolinone or salt thereof solution has an osmolality from about 50mOsmol/kg to about 1000 mOsmol/kg. The nintedanib or indolinone or saltthereof solution has a taste masking agent. The taste masking agent isselected from the group consisting of lactose, sucrose, dextrose,saccharin, aspartame, sucrulose, and ascorbate. In some embodiments,nintedanib or indolinone or salt thereof, solution has a osmolalityadjusting agents suitable for pulmonary delivery, including co-solventsselected from the group consisting of propylene glycol, ethanol,polyethylene glycol 400, and glycerin and combinations thereof. Thesolution further comprises a second anti-fibrotic or anti-cancer oranti-infective agent suitable for pulmonary delivery. The compositionmay be co-administered with a second anti-fibrotic or anti-cancer oranti-infective agent suitable for pulmonary delivery. The compositionco-administered a second anti-inflammatory agent suitable for pulmonarydelivery.

In some embodiments, described herein is a kit comprising: a unit dosageof an aqueous solution of nintedanib or indolinone or salt thereof, asdescribed herein in a container that is adapted for use in a liquidnebulizer.

In some embodiments, described herein is a kit comprising: a unit dosageof an aqueous solution of nintedanib or indolinone or salt thereof andpirfenidone or pyridone analog, as described herein in a container thatis adapted for use in a liquid nebulizer.

Nebulized aqueous nintedanib formulation requires at least 30 mMpermeant ion for good tolerability. However, aqueous nintedanib isunstable at these permeant ion concentrations. To circumvent this issue,aqueous nintedanib may be formulated as a multi-container system foradmixture just prior to use. In one configuration a kit is comprised oftwo-containers for admixture wherein an aqueous solution of nintedanibor indolinone or salt thereof is dissolved in an aqueous solution in afirst container and osmolality adjusting agents, including buffers andpermeant and ions are confined to a separate container having no fluidcommunication between the first and second containers during storage.Just prior to use, the contents of the first and second containers arecombined. The first and second containers may be formed as part of thesame package specially designed for admixture and for transmitting thecontents of the first and second containers once combined into thereservoir of a liquid nebulizer.

In some embodiments, described herein is a unit dosage adapted for usein a liquid nebulizer comprising from about 0.01 mL to about 10 mL of anaqueous solution of nintedanib or salt thereof, wherein theconcentration of nintedanib or salt thereof, in the aqueous solution isfrom about 0.0001 mg/mL to about 10 mg/mL requires admixture prior toadministration. For stability purposes the unit dosage form is preparedas a two-container admixture system, wherein container one containsnintedanib or salt thereof is prepared in an aqueous volume from about0.01 mL to about 10 mL; optionally 0.01 mM to about 1000 mM buffermaintaining a pH from about 3.0 to about 7.0, preferably from about pH3.0 to about pH 6.0; optionally a osmolality adjusting agentconcentration from about 0.1% to about 99%; optionally a taste-maskingagent from about 0.01 mM to about 100 mM. Container 2 consists of anaqueous solution from about 0.01 mL to about 10 mL; optionallycontaining a permeant ion concentration from about 30 mM to about 1500mM, wherein permeant ions may be selected from chloride ion and bromideion; optionally 0.01 mM to about 1000 mM buffer maintaining a pH fromabout 3.0 to about 7.0, preferably from about pH 3.0 to about pH 6.0;optionally a osmolality adjusting agent from about 0.1% to about 99%;optionally a taste-masking agent from about 0.01 mM to about 100 mM.Prior to administration, the two-container admixture system is admixedresulting in a unit dosage form comprising from about 0.01 mL to about10 mL of an aqueous solution of nintedanib or salt thereof, wherein theconcentration of nintedanib or salt thereof, in the aqueous solution isfrom about 0.0001 mg/mL to about 10 mg/mL; optionally 0.01 to about 100mM buffer maintaining a pH from about 3.0 to about 7.0, preferably fromabout pH 3.0 to about pH 6.0; optionally, a osmolality adjusting agentconcentration from about 0.1% to about 20%; optionally a taste-maskingagent from about 0.01 mM to about 10 mM; optionally containing apermeant ion concentration from about 30 mM to about 150 mM, whereinpermeant ions are selected from chloride ion and bromide ion, with afinal admixed solution osmolality from about 50 mOsmol/kg to about 600mOsmol/kg.

In some embodiments, described herein is a unit dosage adapted for usein a liquid nebulizer comprising from about 0.01 mL to about 10 mL of anaqueous solution of nintedanib or salt thereof, wherein theconcentration of nintedanib or salt thereof, in the aqueous solution isfrom about 0.0001 mg/mL to about 10 mg/mL requires admixture prior toadministration. For stability purposes the unit dosage form is preparedas a two-container admixture system, wherein container one containsnintedanib or salt thereof is prepared in an aqueous volume from about0.01 mL to about 10 mL; optionally 0.01 mM to about 1000 mM glycine orglutamate buffer maintaining a pH from about 3.0 to about 7.0,preferably from about pH 3.0 to about pH 6.0; optionally a propyleneglycol at a concentration from about 0.1% to about 99%; optionally ataste-masking agent from about 0.01 mM to about 100 mM. Container 2consists of an aqueous solution from about 0.01 mL to about 10 mL;optionally containing a permeant ion concentration from about 30 mM toabout 1500 mM, wherein permeant ions may be selected from chloride ionand bromide ion; optionally 0.01 mM to about 1000 mM glycine orglutamate buffer maintaining a pH from about 3.0 to about 7.0,preferably from about pH 3.0 to about pH 6.0; optionally propyleneglycol at a concentration from about 0.1% to about 99%; optionally ataste-masking agent from about 0.01 mM to about 100 mM. Prior toadministration, the two-container admixture system is admixed resultingin a unit dosage form comprising from about 0.01 mL to about 10 mL of anaqueous solution of nintedanib or salt thereof, wherein theconcentration of nintedanib or salt thereof, in the aqueous solution isfrom about 0.0001 mg/mL to about 10 mg/mL; optionally 0.01 to about 100mM glycine or glutamate buffer maintaining a pH from about 3.0 to about7.0, preferably from about pH 3.0 to about pH 6.0; optionally, propyleneglycol at a concentration from about 0.1% to about 20%; optionally ataste-masking agent from about 0.01 mM to about 10 mM; optionallycontaining a permeant ion concentration from about 30 mM to about 150mM, wherein permeant ions may be selected from chloride ion and bromideion, with a final admixed solution osmolality from about 50 mOsmol/kg toabout 600 mOsmol/kg.

Described herein is a unit dosage adapted for use in a liquid nebulizercomprising from about 0.01 mL to about 10 mL of an aqueous solution ofnintedanib or salt thereof, wherein the concentration of nintedanibhydrobromide salt, in the aqueous solution is from about 0.0001 mg/mL toabout 5 mg/mL requires admixture prior to administration. For stabilitypurposes the unit dosage form is prepared as a two-container admixturesystem, wherein container one contains nintedanib hydrobromide salt isprepared in an aqueous volume from about 0.01 mL to about 10 mL;optionally 0.01 mM to about 1000 mM glycine or glutamate buffermaintaining a pH from about 3.0 to about 7.0, preferably from about pH3.0 to about pH 6.0; optionally a propylene glycol at a concentrationfrom about 0.1% to about 99%; optionally a taste-masking agent fromabout 0.01 mM to about 100 mM. Container 2 consists of an aqueoussolution from about 0.01 mL to about 10 mL; optionally containing apermeant ion concentration from about 30 mM to about 1500 mM, whereinpermeant ions may be selected from chloride ion and bromide ion;optionally 0.01 mM to about 1000 mM glycine or glutamate buffermaintaining a pH from about 3.0 to about 7.0, preferably from about pH3.0 to about pH 6.0; optionally propylene glycol at a concentration fromabout 0.1% to about 99%; optionally a taste-masking agent from about0.01 mM to about 100 mM. Prior to administration, the two-containeradmixture system is admixed resulting in a unit dosage form comprisingfrom about 0.01 mL to about 10 mL of an aqueous solution of nintedanibhydrobromide salt, wherein the concentration of nintedanib hydrobromidesalt, in the aqueous solution is from about 0.0001 mg/mL to about 5mg/mL; optionally 0.01 to about 50 mM glycine or glutamate buffermaintaining a pH from about 3.0 to about 7.0, preferably from about pH3.0 to about pH 6.0; optionally, propylene glycol at a concentrationfrom about 0.1% to about 20%; optionally a taste-masking agent fromabout 0.01 mM to about 10 mM; optionally containing a permeant ionconcentration from about 30 mM to about 150 mM, wherein permeant ionsmay be selected from chloride ion and bromide ion with a final admixedsolution osmolality from about 50 mOsmol/kg to about 600 mOsmol/kg.

In some embodiments, described herein is a unit dosage adapted for usein a liquid nebulizer comprising from about 0.01 mL to about 10 mL of anaqueous solution of nintedanib or salt thereof, wherein theconcentration of nintedanib hydrochloride salt, in the aqueous solutionis from about 0.0001 mg/mL to about 5 mg/mL requires admixture prior toadministration. For stability purposes the unit dosage form is preparedas a two-container admixture system, wherein container one containsnintedanib hydrochloride salt is prepared in an aqueous volume fromabout 0.01 mL to about 10 mL; optionally 0.01 mM to about 1000 mMglycine or glutamate buffer maintaining a pH from about 3.0 to about7.0, preferably from about pH 3.0 to about pH 6.0; optionally apropylene glycol at a concentration from about 0.1% to about 99%;optionally a taste-masking agent from about 0.01 mM to about 100 mM.Container 2 consists of an aqueous solution from about 0.01 mL to about10 mL; optionally containing a permeant ion concentration from about 30mM to about 1500 mM, wherein permeant ions may be selected from chlorideion and bromide ion; optionally 0.01 mM to about 1000 mM glycine orglutamate buffer maintaining a pH from about 3.0 to about 7.0,preferably from about pH 3.0 to about pH 6.0; optionally propyleneglycol at a concentration from about 0.1% to about 99%; optionally ataste-masking agent from about 0.01 mM to about 100 mM. Prior toadministration, the two-container admixture system is admixed resultingin a unit dosage form comprising from about 0.01 mL to about 10 mL of anaqueous solution of nintedanib hydrochloride salt, wherein theconcentration of nintedanib hydrochloride salt, in the aqueous solutionis from about 0.0001 mg/mL to about 5 mg/mL; optionally 0.01 to about 50mM glycine or glutamate buffer maintaining a pH from about 3.0 to about7.0, preferably from about pH 3.0 to about pH 6.0; optionally, propyleneglycol at a concentration from about 0.1% to about 20%; optionally ataste-masking agent from about 0.01 mM to about 10 mM; optionallycontaining a permeant ion concentration from about 30 mM to about 150mM, wherein permeant ions may be selected from chloride ion and bromideion, with a final admixed solution osmolality from about 50 mOsmol/kg toabout 600 mOsmol/kg.

In some embodiments, described herein is a unit dosage adapted for usein a liquid nebulizer comprising from about 0.01 mL to about 10 mL of anaqueous solution of nintedanib or salt thereof, wherein theconcentration of nintedanib esylate salt, in the aqueous solution isfrom about 0.0001 mg/mL to about 5 mg/mL requires admixture prior toadministration. For stability purposes the unit dosage form is preparedas a two-container admixture system, wherein container one containsnintedanib esylate salt is prepared in an aqueous volume from about 0.01mL to about 10 mL; optionally 0.01 mM to about 1000 mM glycine orglutamate buffer maintaining a pH from about 3.0 to about 7.0,preferably from about pH 3.0 to about pH 6.0; optionally a propyleneglycol at a concentration from about 0.1% to about 99%; optionally ataste-masking agent from about 0.01 mM to about 100 mM. Container 2consists of an aqueous solution from about 0.01 mL to about 10 mL;optionally containing a permeant ion concentration from about 30 mM toabout 1500 mM, wherein permeant ions may be selected from chloride ionand bromide ion; optionally 0.01 mM to about 1000 mM glycine orglutamate buffer maintaining a pH from about 3.0 to about 7.0,preferably from about pH 3.0 to about pH 6.0; optionally propyleneglycol at a concentration from about 0.1% to about 99%; optionally ataste-masking agent from about 0.01 mM to about 10 mM. Prior toadministration, the two-container admixture system is admixed resultingin a unit dosage form comprising from about 0.01 mL to about 10 mL of anaqueous solution of nintedanib esylate salt, wherein the concentrationof nintedanib esylate salt, in the aqueous solution is from about 0.0001mg/mL to about 5 mg/mL; optionally 0.01 to about 50 mM glycine orglutamate buffer maintaining a pH from about 3.0 to about 7.0,preferably from about pH 3.0 to about pH 6.0; optionally, propyleneglycol at a concentration from about 0.1% to about 20%; optionally ataste-masking agent from about 0.01 mM to about 10 mM; optionallycontaining a permeant ion concentration from about 30 mM to about 150mM, wherein permeant ions may be selected from chloride ion and bromideion, with a final admixed solution osmolality from about 50 mOsmol/kg toabout 600 mOsmol/kg.

The invention includes a stand-alone, single-container system whereinnintedanib or salt thereof, or an indolinone derivative are stabilizedin the presence of pH, and ion concentration, buffer content,osmolality, or other parameters that are otherwise incompatible withnintedanib or indolinone composition as the active pharmaceuticalingredient. The addition of the active ingredient pirfenidone orpyridone analog further increases nintedanib or indolinone compositionstability, increases aqueous solubility, and reduces viscosity thatotherwise exists at high nintedanib or indolinone compositionconcentrations greater than about 10 mg/mL to about 50 mg/mL. At theseand lower nintedanib or salt thereof, or an indolinone derivativeconcentrations, the addition of active ingredient pirfenidone orpyridone analog enables formulation of nintedanib or salt thereof, or anindolinone derivative in a stable, single container solution containingion concentrations, buffer contents, osmolality, pH or other parametersthat are otherwise incompatible as a single solution product. For this,the formulation as administered may be prepared as a unit dosage adaptedfor use in a liquid nebulizer comprising from about 0.01 mL to about 10mL of an aqueous solution of nintedanib or salt thereof, or a indolinonederivative or salt thereof at a concentration from about 0.0001 mg/mL toabout 50 mg/mL, and pirfenidone or pyridone analog at a concentrationfrom about 5 mg/mL to about 20 mg/mL, optionally one or more osmolalityadjusting agents at a concentration of about 0.1% to about 20% to adjustosmolality, inorganic salts at a concentration of about 15 mM to about500 mM to adjust osmolality and provide a permeant ion at a finalconcentration from about 30 mM to about 500 mM; and optionally one ormore buffers to maintain the pH between about pH 3.0 to about pH 7.0,preferably from about pH 3.0 to about pH 6.0, with a final osmolalitybetween 50 mOsmo/kg and 1000 mOsmo/kg. The aqueous solution may includeone or more osmolality adjusting agents, including co-solvents selectedfrom propylene glycol, ethanol, glycerin, and mannitol and combinationsthereof at a concentration from about 0.1% to about 20%. The aqueoussolution includes one more inorganic salts selected from hydrogenchloride, hydrogen bromide, sodium chloride, magnesium chloride, calciumchloride, potassium chloride, sodium bromide, potassium bromide,magnesium bromide and calcium bromide and combinations thereof. Theinorganic salt content of the aqueous solution is from about 15 mM toabout 300 mM. The buffer is selected from one or more of lysinate,acetylcysteine, glycine, glutamate, borate, succinate, tartrate,phosphate or Tris and combinations thereof, the pH of the aqueoussolution is from about pH 3.0 to about pH 7.0, preferably pH about 3.0to about pH 6.0. In some embodiments, described herein is an aqueoussolution for nebulized inhalation administration comprising: water;nintedanib or salt thereof, at a concentration from about 0.005 mg/mL toabout 50 mg/mL; pirfenidone or pyridone analog at a concentration fromabout 5 mg/mL to about 20 mg/mL; one or more permeant ions; one or moreosmolality adjusting agents; and wherein the osmolality of the aqueoussolution is from about 50 mOsmol/kg to about 1000 mOsmol/kg.

The invention includes a population of aqueous droplets of nintedanib orindolinone or salt thereof wherein the aqueous droplet has a meandiameter less than about 5.0 μm that may collectively be referred to asan aerosol mist. The population of droplets is produced from a liquidnebulizer having an aqueous solution of nintedanib or indolinone or saltthereof disposed in the reservoir of the nebulizer. The aqueous solutionof nintedanib or indolinone or salt thereof having a concentration ofnintedanib or salt thereof, from about 0.0001 mg/mL to about 10 mg/mL, apermeant ion concentration from about 30 mM to about 150 mM and anosmolality from about 50 mOsmol/kg to about 600 mOsmol/kg.

The invention includes a population of aqueous droplets of nintedanib orindolinone or salt thereof and pirfenidone or pyridone analog whereinthe aqueous droplet has a mean diameter less than about 5.0 μm that maycollectively be referred to as an aerosol mist. The population ofdroplets is produced from a liquid nebulizer having an aqueous solutionof nintedanib or indolinone or salt thereof and pirfenidone or pyridoneanalog disposed in the reservoir of the nebulizer. The aqueous solutionof nintedanib or indolinone or salt thereof and pirfenidone or pyridoneanalog having a concentration of nintedanib or salt thereof, from about0.0001 mg/mL to about 50 mg/mL and pirfenidone or pyridone analogconcentration from about 5 mg/mL to about 20 mg/mL, a permeant ionconcentration from about 30 mM to about 500 mM and an osmolality fromabout 50 mOsmol/kg to about 1000 mOsmol/kg.

An aqueous aerosol comprising a plurality of aqueous droplets has avolumetric mean diameter (VMD), mass median aerodynamic diameter (MMAD),and/or mass median diameter (MMD) of less than about 5.0 μm. In someembodiments, at least 20% of the aqueous droplets in the aerosol have adiameter less than about 5 μm.

Although as described below, “high efficiency” liquid nebulizers arepreferred for production of the aerosol mist, a number of differentnebulizer designs exist including a jet nebulizer, an ultrasonicnebulizer, a pulsating membrane nebulizer, a nebulizer comprising avibrating mesh or plate with multiple apertures, or a nebulizercomprising a vibration generator and an aqueous chamber. A preferredhigh efficiency nebulizer is comprised of a vibrating mesh or plate withmultiple apertures that is in fluid communication with a reservoir forcontaining the admixture described herein. The liquid nebulizerpreferably: (i) achieves lung deposition of at least 7% of thenintedanib or indolinone or salt thereof to the lung of an adult human;(ii) provides a Geometric Standard Deviation (GSD) of emitted dropletsize distribution of the aqueous solution of about 1.0 μm to about 2.5μm; (iii) provides: a) a mass median aerodynamic diameter (MMAD) ofdroplet size of the aqueous solution emitted with the high efficiencyliquid nebulizer of about 1 μm to about 5 μm; b) a volumetric meandiameter (VMD) of about 1 μm to about 5 μm; and/or c) a mass mediandiameter (MMD) of about 1 μm to about 5 μm; (iv) provides a fineparticle fraction (FPF=%≤5 microns) of droplets emitted from the liquidnebulizer of at least about 30%; (v) provides an output rate of at least0.1 mL/min; and/or (vi) provides at least about 25% of the aqueoussolution to the patient.

The liquid nebulizer preferably possesses at least two, at least three,at least four, at least five, or all six of parameters (i), (ii), (iii),(iv), (v), (vi) listed above and preferably achieves lung deposition of(i) at least 5%, at least 6%, at least 7%, at least 8%, at least 9%, atleast 10%, at least 12%, at least 14%, at least 16%, at least 18%, atleast 20%, at least 25%, at least 30%, at least 35%, at least 40% atleast 45%, at least 50%, at least 55%, at least 60%, at least 65%, atleast 70%, at least 75%, or at least 80% of the nintedanib or indolinoneor salt thereof, or nintedanib or indolinone or salt thereof andpirfenidone or pyridone analog administered to the patient. The liquidnebulizer: (ii) provides a Geometric Standard Deviation (GSD) of emitteddroplet size distribution of the aqueous solution of about 1.0 μm toabout 2.5 μm, about 1.2 μm to about 2.3 μm, about 1.4 μm to about 2.1μm, or about 1.5 μm to about 2.0 μm. The liquid nebulizer: (iii)provides a) a mass median aerodynamic diameter (MMAD) of droplet size ofthe aqueous solution emitted with the high efficiency liquid nebulizerof about less than 5 μm or about 1 μm to about 5 μm; b) a volumetricmean diameter (VMD) of about less than 5 μm or about 1 μm to about 5 μm;and/or c) a mass median diameter (MMD) of about less than 5 μm or about1 μm to about 5 μm. The liquid nebulizer: (iv) provides a fine particlefraction (FPF=%≤5 microns) of droplets emitted from the liquid nebulizerof at least about 30%, at least about 35%, at least about 40%, at leastabout 45%, at least about 50%, at least about 55%, at least about 60%,at least about 65%, at least about 70%, at least about 75%, at leastabout 80%, at least about 85%, or at least about 90%.The liquidnebulizer: (v) provides an output rate of at least 0.1 mL/min, of atleast 0.2 mL/min, of at least 0.3 mL/min, of at least 0.4 mL/min, of atleast 0.5 mL/min, of at least 0.6 mL/min, of at least 0.7 mL/min, of atleast 0.8 mL/min, of at least 0.9 mL/min, of at least 1.0 mL/min, orless than about 1.0 mL/min. The liquid nebulizer: (vi) provides at leastabout 25%, at least about 30%, at least about 35%, at least about 40%,at least about 45%, at least about 50%, at least about 55%, at leastabout 60%, at least about 65%, at least about 70%, at least about 75%,at least about 80%, at least about 85%, or at least about 95%,of theaqueous solution to the mammal. The liquid nebulizer provides anrespirable delivered dose (RDD) of at least 5%, at least 6%, at least7%, at least 8%, at least 10%, at least 12%, at least 16%, at least 20%,at least 24%, at least 28%, at least 32%, at least 36%, at least 40%, atleast 45%, at least 50%, at least 55%, at least 60%, at least 65%, atleast 70%, at least 75%, at least 80%, at least 85%, or at least 90%.

The pharmaceutical compositions and methods of the present inventioninclude preparing and administering specific formulations havingdiscrete ranges of concentration, osmolality, and permeant ionconcentration in order to generate an aerosol that achieves specificlevels of deposition of active ingredient to the lung. The compositioncomprising nintedanib or indolinone or salt thereof is prepared in anaqueous solution and administered to the patient with a liquidnebulizer; wherein the aqueous solution comprises water; nintedanib orindolinone or salt thereof, at a concentration from about 0.001 mg/mL toabout 10 mg/mL; wherein the osmolality of the aqueous solution is fromabout 50 mOsmol/kg to about 600 mOsmol/kg. The liquid (i) achieves lungdeposition of at least 7% of the nintedanib or indolinone or saltthereof administered to the mammal; (ii) provides a Geometric StandardDeviation (GSD) of emitted droplet size distribution of the aqueoussolution of about 1.0 μm to about 2.5 μm; (iii) provides: a) a massmedian aerodynamic diameter (MMAD) of droplet size of the aqueoussolution emitted with the high efficiency liquid nebulizer of about 1 μmto about 5 μm; b) a volumetric mean diameter (VMD) of about 1 μm toabout 5 μm; and/or c) a mass median diameter (MMD) of about 1 μm toabout 5 μm; (iv) provides a fine particle fraction (FPF=%≤5 microns) ofdroplets emitted from the liquid nebulizer of at least about 30%; (v)provides an output rate of at least 0.1 mL/min; and/or (vi) provides atleast about 25% of the aqueous solution to the mammal. The liquidnebulizer delivers from about 0.0001 mg to about 100 mg of nintedanib orindolinone or salt thereof compound to the lungs of the patient in lessthan about 20 minutes with mass median diameter (MMAD) particles sizesfrom about 1 to about 5 micron.

The pharmaceutical compositions and methods of the present inventioninclude preparing and administering specific formulations havingdiscrete ranges of concentration, osmolality, and permeant ionconcentration in order to generate an aerosol that achieves specificlevels of deposition of active ingredient to the lung. The compositioncomprising nintedanib or indolinone or salt thereof and pirfenidone orpyridone analog is prepared in an aqueous solution and administered tothe patient with a liquid nebulizer; wherein the aqueous solutioncomprises water; nintedanib or indolinone or salt thereof at aconcentration from about 0.0001 mg/mL to about 50 mg/mL and pirfenidoneor pyridone analog at a concentration from about 5 mg/mL to about 20mg/mL; wherein the osmolality of the aqueous solution is from about 50mOsmol/kg to about 1000 mOsmol/kg. The liquid (i) achieves lungdeposition of at least 7% of the nintedanib or indolinone or saltthereof administered to the mammal; (ii) provides a Geometric StandardDeviation (GSD) of emitted droplet size distribution of the aqueoussolution of about 1.0 μm to about 2.5 μm; (iii) provides: a) a massmedian aerodynamic diameter (MMAD) of droplet size of the aqueoussolution emitted with the high efficiency liquid nebulizer of about 1 μmto about 5 μm; b) a volumetric mean diameter (VMD) of about 1 μm toabout 5 μm; and/or c) a mass median diameter (MMD) of about 1 μm toabout 5 μm; (iv) provides a fine particle fraction (FPF=%≤5 microns) ofdroplets emitted from the liquid nebulizer of at least about 30%; (v)provides an output rate of at least 0.1 mL/min; and/or (vi) provides atleast about 25% of the aqueous solution to the mammal. The liquidnebulizer delivers from about 0.0001 mg to about 100 mg of nintedanib orindolinone or salt thereof and from about 1 mg to about 20 mgpirfenidone or pyridone analog compounds to the lungs of the patient inless than about 20 minutes with mass median diameter (MMAD) particlessizes from about 1 to about 5 micron.

The methods for the treatment of lung disease in a mammal comprising:administering to mammal in need thereof an aqueous solution comprisingnintedanib or indolinone or salt thereof, with a liquid nebulizer.Described herein is a method for the treatment of lung disease in amammal comprising: administering to mammal in need thereof an aqueoussolution comprising nintedanib or salt thereof with a liquid nebulizer;wherein the aqueous solution comprises water; nintedanib or salt thereofat a concentration from about 0.0001 mg/mL to about 10 mg/mL; optionallyone or more inorganic salts, wherein the osmolality of the aqueoussolution is from about 50 mOsmol/kg to about 600 mOsmol/kg; optionally apermeant ion from about 30 mM to about 150 mM; optionally one or morebuffers maintaining the solution pH between about 3.0 and 7.0;optionally a osmolality adjusting agent from about 0.1 to about 20%;optionally a taste-masker from about 0.01 mM to about 10 mM. Thenebulizer is a jet nebulizer, an ultrasonic nebulizer, a pulsatingmembrane nebulizer, a nebulizer comprising a vibrating mesh or platewith multiple apertures, or a nebulizer comprising a vibration generatorand an aqueous chamber. In some embodiments, the liquid nebulizer: (i)achieves lung deposition of at least 7% of the nintedanib or indolinoneor salt thereof, administered to the mammal; (ii) provides a GeometricStandard Deviation (GSD) of emitted droplet size distribution of theaqueous solution of about 1.0 μm to about 2.5 μm; (iii) provides: a) amass median aerodynamic diameter (MMAD) of droplet size of the aqueoussolution emitted with the high efficiency liquid nebulizer of about 1 μmto about 5 μm; b) a volumetric mean diameter (VMD) of about 1 μm toabout 5 μm; and/or c) a mass median diameter (MMD) of about 1 μm toabout 5 μm; (iv) provides a fine particle fraction (FPF=%≤5 microns) ofdroplets emitted from the liquid nebulizer of at least about 30%; (v)provides an output rate of at least 0.1 mL/min; and/or (vi) provides atleast about 25% of the aqueous solution to the mammal.

The methods for the treatment of lung disease in a mammal comprising:administering to mammal in need thereof an aqueous solution comprisingnintedanib or indolinone or salt thereof and pirfenidone or pyridoneanalog with a liquid nebulizer. Described herein is a method for thetreatment of lung disease in a mammal comprising: administering tomammal in need thereof an aqueous solution comprising nintedanib or saltthereof and pirfenidone or pyridone analog with a liquid nebulizer;wherein the aqueous solution comprises water; nintedanib or salt thereofat a concentration from about 0.0001 mg/mL to about 50 mg/mL andpirfenidone or pyridone analog at a concentration from about 5 mg/mL toabout 20 mg/mL; optionally one or more inorganic salts, wherein theosmolality of the aqueous solution is from about 50 mOsmol/kg to about1000 mOsmol/kg; optionally a permeant ion from about 30 mM to about 500mM; optionally one or more buffers maintaining the solution pH betweenabout 3.0 and 7.0; optionally a osmolality adjusting agent from about0.1 to about 10%; optionally a taste-masker from about 0.01 mM to about10 mM. The nebulizer is a jet nebulizer, an ultrasonic nebulizer, apulsating membrane nebulizer, a nebulizer comprising a vibrating mesh orplate with multiple apertures, or a nebulizer comprising a vibrationgenerator and an aqueous chamber. In some embodiments, the liquidnebulizer: (i) achieves lung deposition of at least 7% of the nintedanibor indolinone or salt thereof, administered to the mammal; (ii) providesa Geometric Standard Deviation (GSD) of emitted droplet sizedistribution of the aqueous solution of about 1.0 μm to about 2.5 μm;(iii) provides: a) a mass median aerodynamic diameter (MMAD) of dropletsize of the aqueous solution emitted with the high efficiency liquidnebulizer of about 1 μm to about 5 μm; b) a volumetric mean diameter(VMD) of about 1 μm to about 5 μm; and/or c) a mass median diameter(MMD) of about 1 μm to about 5 μm; (iv) provides a fine particlefraction (FPF=% 5 microns) of droplets emitted from the liquid nebulizerof at least about 30%; (v) provides an output rate of at least 0.1mL/min; and/or (vi) provides at least about 25% of the aqueous solutionto the mammal.

The liquid nebulizer delivers about 0.0001 mg to about 100 mg ofnintedanib or indolinone or salt thereof to the lungs in less than about20 minutes with mass median diameter (MMAD) particles sizes from about 1to about 5 micron.

The liquid nebulizer delivers about 0.0001 mg to about 100 mg ofnintedanib or indolinone or salt thereof and about 1 mg to about 20 mgpirfenidone or pyridone analog to the lungs in less than about 20minutes with mass median diameter (MMAD) particles sizes from about 1 toabout 5 micron.

The aqueous droplet populations have a median diameter less than about5.0 μm. The aqueous droplet has a diameter less than about 5.0 μm, lessthan about 4.5 μm, less than about 3.0 μm, less than about 3.5 μm, lessthan about 3.0 μm, less than about 2.5 μm, less than about 2.0 μm, lessthan about 1.5 μm, or less than about 1.0 μm and are further comprisedof one or more osmolality adjusting agents including co-solventsselected from ethanol, propylene glycol, mannitol and glycerin andcombinations thereof. The aqueous droplet may also be further comprisedof a buffer selected from lysinate, acetylcysteine, glycine, glutamate,borate, succinate, tartrate, phosphate or Tris and combinations thereof.

The aqueous droplet populations may exhibit a varying range in thepercent of individual droplets above 5 μm such as: and may vary from atleast about 15% , 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%,70%,75%, 80%, 85%, or 90%.

In some embodiments, administration with the liquid nebulizer does notinclude an initial dose-escalation period.

In one example, about 0.01 mL to about 10 mL of the aqueous solution isadministered to the mammal with a liquid nebulizer, the solutioncomprising nintedanib or salt thereof, at a concentration from about0.0001 mg/mL to about 10 mg/mL; optionally one or more inorganic salts,wherein the osmolality of the aqueous solution is from about 50mOsmol/kg to about 600 mOsmol/kg; optionally a permeant ion from about30 mM to about 150 mM; optionally one or more buffers maintaining thesolution pH between about 3.0 and 7.0; optionally a osmolality adjustingagent from about 0.1 to about 20%; optionally a taste-masker from about0.01 mM to about 10 mM; and the liquid nebulizer is a nebulizercomprising a vibrating mesh or plate with multiple apertures, the liquidnebulizer delivers about 0.0001 mg to about 100 mg of nintedanib or saltthereof to the lungs in less than about 20 minutes with mass mediandiameter (MMAD) particles sizes from about 1 to about 5 micron.

In one example, about 0.01 mL to about 10 mL of the aqueous solution isadministered to the mammal with a liquid nebulizer, the solutioncomprising nintedanib or salt thereof, at a concentration from about0.0001 mg/mL to about 50 mg/mL and pirfenidone or pyridone analog at aconcentration from about 5 mg/mL to about 20 mg/mL; optionally one ormore inorganic salts, wherein the osmolality of the aqueous solution isfrom about 50 mOsmol/kg to about 1000 mOsmol/kg; optionally a permeantion from about 30 mM to about 500 mM; optionally one or more buffersmaintaining the solution pH between about 3.0 and 7.0; optionally aosmolality adjusting agent from about 0.1 to about 20%; optionally ataste-masker from about 0.01 mM to about 10 mM; and the liquid nebulizeris a nebulizer comprising a vibrating mesh or plate with multipleapertures, the liquid nebulizer delivers about 0.0001 mg to about 100 mgof nintedanib or salt thereof and from about 1 mg to about 20 mgpirfenidone or pyridone analog to the lungs in less than about 20minutes with mass median diameter (MMAD) particles sizes from about 1 toabout 5 micron.

In the multi-container approach, a first container contains nintedanibor salt thereof dissolved in an aqueous volume from about 0.01 mL toabout 10 mL; optionally 0.01 mM to about 1000 mM buffer maintaining a pHfrom about 3.0 to about 7.0, preferably from about pH 3.0 to about pH6.0, optionally a osmolality adjusting agent concentration from about0.1% to about 99% and optionally a taste-masking agent from about 0.01mM to about 100 mM. Because nintedanib lacks long-term stability in thepresence of permeant ion, permeant ion is prepared in a separate, secondcontainer. The second container contains an aqueous solution from about0.01 mL to about 10 mL; optionally containing a concentration from about15 mM to about 1500 mM inorganic salt; optionally 0.01 mM to about 1000mM buffer maintaining a pH from about 3.0 to about 7.0, preferably fromabout pH 3.0 to about pH 6.0; optionally a osmolality adjusting agentfrom about 0.1% to about 99%; optionally a taste-masking agent fromabout 0.01 mM to about 100 mM. Just prior to administration, thetwo-container system is admixed resulting in a unit dosage formcomprising from about 0.01 mL to about 10 mL of an aqueous solution ofnintedanib or salt thereof, wherein the concentration of nintedanib orsalt thereof in the aqueous solution is from about 0.01 mg/mL to about10 mg/mL; optionally 0.01 to about 100 mM buffer maintaining a pH fromabout 3.0 to about 7.0, preferably from about pH 3.0 to about pH 6.0;optionally, a osmolality adjusting agent concentration from about 0.1%to about 20%; optionally a taste-masking agent from about 0.01 mM toabout 10 mM; optionally an inorganic salt from about 15 mM to about 300mM, creating a permeant ion concentration from about 30 mM to about 150mM, with a final admixed solution osmolality from about 50 mOsmol/kg toabout 600 mOsmol/kg.

In the unit dose approach, the container contains nintedanib or saltthereof and pirfenidone or pyridone analogy dissolved in an aqueousvolume from about 0.01 mL to about 10 mL; optionally 0.01 mM to about100 mM buffer maintaining a pH from about 3.0 to about 7.0, preferablyfrom about pH 3.0 to about pH 6.0, optionally a osmolality adjustingagent concentration from about 0.1% to about 20%, an inorganic salt fromabout 15 mM to about 500 mM, providing a permeant ion concentration fromabout 30 mM to about 500 mM, and optionally a taste-masking agent fromabout 0.01 mM to about 100 mM. Because pirfenidone stabilizes nintedanibin the presence of permeant ion, this approach permits a stable singlecontainer, unit dose configuration. This single container systemprovides a unit dosage form comprising from about 0.01 mL to about 10 mLof an aqueous solution of nintedanib or salt thereof and pirfenidone orpyridone analog, wherein the concentration of nintedanib or salt thereofin the aqueous solution is from about 0.01 mg/mL to about 50 mg/mL andthe concentration of pirfenidone or pyridone analog is from about 5mg/ml to about 20 mg/mL; optionally 0.01 to about 100 mM buffermaintaining a pH from about 3.0 to about 7.0, preferably from about pH3.0 to about pH 6.0; optionally, a osmolality adjusting agentconcentration from about 0.1% to about 20%; optionally a taste-maskingagent from about 0.01 mM to about 10 mM; optionally an inorganic saltfrom about 15 mM to about 500 mM, creating a permeant ion concentrationfrom about 30 mM to about 500 mM, with a final admixed solutionosmolality from about 50 mOsmol/kg to about 1000 mOsmol/kg.

In the unit dose approach, the container contains nintedanibhydrobromide and pirfenidone dissolved in an aqueous volume from about0.01 mL to about 10 mL; optionally 0.01 mM to about 100 mM buffermaintaining a pH from about 3.0 to about 7.0, preferably from about pH3.0 to about pH 6.0, optionally a osmolality adjusting agentconcentration from about 0.1% to about 20%, an inorganic salt from about15 mM to about 500 mM, providing a permeant ion concentration from about30 mM to about 500 mM, and optionally a taste-masking agent from about0.01 mM to about 100 mM. Because pirfenidone stabilizes nintedanib inthe presence of permeant ion, this approach permits a stable singlecontainer, unit dose configuration. This single container systemprovides a unit dosage form comprising from about 0.01 mL to about 10 mLof an aqueous solution of nintedanib hydrobromide and pirfenidone,wherein the concentration of nintedanib hydrobromide in the aqueoussolution is from about 0.01 mg/mL to about 50 mg/mL and theconcentration of pirfenidone is from about 5 mg/ml to about 20 mg/mL;optionally 0.01 to about 100 mM buffer maintaining a pH from about 3.0to about 7.0, preferably from about pH 3.0 to about pH 6.0; optionally,a osmolality adjusting agent concentration from about 0.1% to about 20%;optionally a taste-masking agent from about 0.01 mM to about 10 mM;optionally an inorganic salt from about 15 mM to about 500 mM, creatinga permeant ion concentration from about 30 mM to about 500 mM, with afinal admixed solution osmolality from about 50 mOsmol/kg to about 1000mOsmol/kg.

The invention includes a dry powder formulation for oral comprisingnintedanib or salt thereof, or a indolinone derivative or salt thereof,at concentrations of 0.1% w/w to about 100% w/w in a finely divided formhaving mass median diameters of 0.5 micrometers to 10 micrometers. Thenintedanib or salts thereof, or a indolinone or salt thereof andoptionally one or more carrier excipients (e.g. lactose, mannitol,sucrose, glucose, trehalose) at about 10% to about 99.99% to improvehandling, dispensing, metering and dispersion of the drug. Theformulation may optionally contain one or more slipping agents (e.g.,L-leucine, magnesium stearate) at a concentration of about 0.1% w/w toabout 10% w/w to reduce inter-particulate adhesion, improve powderflowability and reduce moisture effects. The formulations may beprepared by physical blending of nintedanib or salt thereof, with theaforementioned excipients. Alternatively, the dry powder formulation mayform by precipitation techniques that include spray drying, vacuumdrying, solvent extraction, controlled precipitation, emulsification orlyophilization. For these formulations, in addition to the excipientsmentioned above for blended dry powder formulations, these may containphospholipids (e.g., dip almitoylphosphatidylcholine,disteroylphosphatidylcholine, diarachidoylphosphatidylcholinedibehenoylphosphatidylcholine, diphosphatidyl glycerol) at 10% w/w toabout 99.9% w/w to act as emulsifying agent and bulking agent.Optionally the formulation of the present invention may also include abiocompatible, preferably biodegradable polymer, copolymer, or blend orother combination thereof at about 0.1% w/w 99.9% w/w. Examples ofpolymers include but not limited to polylactides,polylactide-glycolides, cyclodextrins, polyacrylates, methylcellulose,carboxymethylcellulose, polyvinyl alcohols, polyanhydrides, polylactams,polyvinyl pyrrolidones, polysaccharides (dextrans, starches, chitin,chitosan, etc.), hyaluronic acid, proteins, (albumin, collagen, gelatin,etc.). The dry powder can be packaged as unit dose in blister pack orcapsules at fill weights of 1 mg to 100 mg. Alternatively, the drypowder formulation can be packaged in a device reservoir that meters 1mg to 100 mg at the point of use.

A vial contains a dry powder comprising of nintedanib or salt thereof,or a indolinone derivative or salt thereof at a concentration,optionally an inorganic salt containing permeant ion(s), optionally abuffer, optionally a non-ionic osmolality adjusting agent and optionallya taste masking agent, and optionally a bulking agent. These componentsmay be prepared by mechanical blending, or by precipitation techniquesknown in the art that include spray drying, vacuum drying, solventextraction, controlled precipitation, emulsification or lyophilization.The weight of the contents in the dry powder vial is about 0.05 gram to1 gram. A second vial contains a diluent comprising of water, optionallyone or more solvents, optionally one or more an inorganic saltcontaining permeant ion(s), optionally a buffer, optionally anosmolality adjusting agent and optionally a taste masking agent. Thevolume of the contents in the diluent vial is about 0.5 mL to 10 mL. Alyophilized vial contains nintedanib or its derivative, optionally aninorganic salt containing permeant ion(s) (e.g., NaCl, NaBr, MgCl2),optionally a buffer (e.g., glycinate, glutamate, maleate, malate),optionally a non-ionic osmolality adjusting agent (e.g., lactose,mannitol, sucrose), and optionally a taste masking agent, and optionallya bulking agent (e.g. lactose, mannitol, sucrose). A diluent vialcontains sterile water, optionally an inorganic salt containing permeantion(s) (e.g., NaCl, NaBr, MgCl2, CaCl2, CaBr, MgBr2, HCl, HBr),optionally a buffer (e.g., glycinate, glutamate, maleate, malate),optionally an osmolality adjusting agent (e.g., lactose, mannitol,glucose, sucrose), and optionally a taste masking agent. The lyophilizedsolution would be reconstituted with the diluent solution at the pointof use.

Osmolality adjusting agents are comprised of consists of one or moreclasses of excipients from the following groups: sugars, alcohols,inorganic salts, amino acids, and acids/bases and combinations thereof.Individually, sugars can be selected from, but not limited to: glucose,fructose, lactose, sucrose, maltose, mannose, trehalose and xylose.Alcohols include but not limited to: erythritol, glycerol, inositol,maltitol, mannitol, menthol, propylene glycol, sorbitol, xylitol,threitol, propylene glycol. Inorganic salts may include but not limitedto: sodium acetate, sodium bromide, sodium chloride, sodium sulfate,sodium phosphate, sodium carbonate, sodium bicarbonate, potassiumcarbonate, potassium iodide, potassium chloride, potassium bromide,magnesium chloride, calcium chloride Amino acids include, but notlimited to: arginine, asparagine, aspartic acid, glutamic acid,glutamine, glycine, histidine, lysine and proline. Finally, acids andbases may include, but not limited to: boric acid, acetic acid, hydrogenbromide, hydrogen chloride, sulfuric acid, nitric acid, phosphoric acid,sodium hydroxide, sodium hydroxide, potassium hydroxide and calciumhydroxide

At the point of use, the contents in the diluent vial is added to thecontents in the dry powder vial to make a reconstituted solution fornebulization comprising water; nintedanib or salt thereof, or aindolinone derivative or salt thereof at a concentration from about0.005 mg/mL to about 10 mg/mL; optional osmolality adjusting agent at aconcentration of about 0.1% to about 20% to adjust osmolality, optionalinorganic salts at a concentration of about 15 mM to about 300 mM toadjust osmolality and provide a permeant ion at a final concentrationfrom about 30 mM to about 150 mM; and optional buffers from about 0.01mM to 100 mM to maintain the pH between about pH 3.0 to about pH 7.0,preferably from about pH 3.0 to about pH 6.0, with a final osmolalitybetween 50 mOsmo/kg and 600 mOsmo/kg. The osmolality adjusting agentsused in the diluent solution may include one or more co-solventsselected from propylene glycol, ethanol, glycerin and mannitol andcombinations thereof to produce a final concentration from about 0.1% toabout 20% in the reconstituted solution. The inorganic salts used ineither the dry powder vial or the diluent vialare selected from sodiumchloride, magnesium chloride, calcium chloride, potassium chloride,sodium bromide, potassium bromide, magnesium bromide and calcium bromideand combinations thereof. The inorganic salt content in thereconstituted aqueous solution is from about 15 mM to about 300 mM. Thebuffer is selected from one or more of lysinate, acetylcysteine,glycine, glutamate, borate, succinate, tartrate, phosphate or Tris andcombinations thereof, the pH of the reconstituted aqueous solution isfrom about pH 3.0 to about pH 7.0, preferably pH about 3.0 to about pH6.0. Described herein is a reconstituted aqueous solution for nebulizedinhalation administration comprising: water; nintedanib or salt thereof,at a concentration from about 0.005 mg/mL to about 10 mg/mL, preferablynot exceeding 5.0 mg/mL; one or more permeant ions at a concentrationfrom about 30 mM to 150 mM; one or more osmolality adjusting agents; andwherein the osmolality of the aqueous solution is from about 50mOsmol/kg to about 600 mOsmol/kg. The formulation may be administered asan inhaled aerosol created from a dosing volume ranging from about 0.01mL to about 10 mL. The formulation may be administered as an inhaledaerosol over a few breaths or by tidal breathing up to 20 minutes.

Methods to Treat or Prevent Disease

For purposes of the methods described herein, a indolinone, salt orderivative thereof compound, most preferably nintedanib salt isadministered using a liquid nebulizer having a vibrating mesh screenthat produces an aerosol mist having a particle size distributionoptimized for delivery of the aerosol to the pulmonary compartment. Insome embodiments, nintedanib or an indolinone derivative compound orsalt thereof is formulated as a pharmaceutical composition suitable foraerosol formation, dose for indication, deposition location, pulmonaryor intra-nasal delivery for pulmonary, intranasal/sinus, orextra-respiratory therapeutic action, good taste, manufacturing andstorage stability, and patient safety and tolerability. The methodsinclude steps for performing an admixture of solutions contained in amulti-container system that separates the active pharmaceuticalingredient (API) from other solutions prior to or immediately followingplacement into a nebulizer for aerosol administration.

The methods include administering a second anti-fibrotic, anti-cancer,anti-infective anti-inflammatory, or anti-pulmonary hypertension agent.The pulmonary diseases subject to treatment under the present inventioninclude interstitial lung disease, such as idiopathic pulmonaryfibrosis, and radiation-therapy-induced pulmonary fibrosis, chronic lungallograft dysfunction, bronchiolitis obliterans, restrictive allograftsyndrome, and systemic sclerosis associated interstitial lung disease(SSc-ILD).The pulmonary diseases also include chronic obstructivepulmonary disease, chronic bronchitis, and cancer, including small celllung cancer, large cell carcinoma, mesothelioma, lung carcinoid tumorsor bronchial cardinoids, secondary lung cancer resulting from metastaticdisease, non-small cell lung cancer, bronchioloalveolar carcinoma,sarcoma, and lymphoma.

The inhaling step is performed in less than about 10 minutes, less thanabout 7.5 minutes, less than about 5 minutes, less than about 2.5minutes, less than about 1.5 minutes, and less than about 30 seconds.The inhaling step may be performed in less than 5 breaths, less than 3breaths, or less than bout 2 breaths.

The methods include to treat a neurologic disease comprising intranasalinhalation of the aerosol described herein.

Intranasal delivery includes the method of administering ananti-demyelination agent to nasal cavity of a patient, comprising:

In the methods described herein involving admixture of separatecontainers, the methods include the affirmative steps of opening andadmixing the contents of at least two sterile single-use containerswhose final admixed solution contains between about 0.01 mL to about 10mL of a solution of nintedanib or indolinone or salt thereof forintroduction into a nebulizer immediately prior to administration to apatient.

In the methods described herein, the aerosol comprises particles havinga mean aerodynamic diameter from about 1 micron to about 5 microns. Theaerosol has a mean particle size from about 1 microns to about 20 μm andpreferably from about 1 5 microns volumetric mean diameter and aparticle size geometric standard deviation of less than or equal to 3microns. The inhaling step delivers a dose of a least 0.0001 mgnintedanib or indolinone or salt thereof, at least 0.001 mg, at least0.01 mg, at least 0.1 mg, at least 1.0 mg, at least 10 mg, at least 50mg, at least 100 mg nintedanib or indolinone or salt thereof.

In the methods described herein, the aerosol comprises particles havinga mean aerodynamic diameter from about 1 micron to about 5 microns. Theaerosol has a mean particle size from about 1 microns to about 20 μm andpreferably from about 1 5 microns volumetric mean diameter and aparticle size geometric standard deviation of less than or equal to 3microns. The inhaling step delivers a dose of a least 0.0001 mg, atleast 0.001 mg, at least 0.01 mg, at least 0.1 mg, at least 1.0 mg, atleast 10 mg, at least 50 mg, at least 100 mg nintedanib or indolinone orsalt thereof and at least 1 mg, at least 2 mg, at least 3 mg, at least 4mg, at least 5 mg, at least 10 mg, at least 50 mg, at least 100 mgpirfenidone or pyridone analog.

In one aspect, described herein is a method for the treatment methodsinclude of administering nintedanib or indolinone or salt thereof, totreat a patient, wherein the patient avoids abnormal liver functionexhibited by a grade 2 or higher abnormality following oraladministration in one or more biomarkers of liver function afternintedanib or indolinone or salt thereof, administration, comprisingadministering to said patient nintedanib or indolinone or salt thereof,at doses less than 1056 mg per day. “Grade 2 liver functionabnormalities” include elevations in alanine transaminase (ALT),aspartate transaminase (AST), alkaline phosphatase (ALP), orgamma-glutamyl transferase (GGT) greater than 2.5-times and less than orequal to 5-times the upper limit of normal (ULN). Grade 2 liver functionabnormalities also include elevations of bilirubin levels greater than1.5-times and less than or equal to 3-times the ULN. The nintedanib orindolinone or salt thereof, is delivered to the patient by oralinhalation or intranasal inhalation. One or more biomarkers of liverfunction is selected from the group consisting of alanine transaminase,aspartate transaminase, bilirubin, and alkaline phosphatase. The methodfurther comprises the step of measuring one or more biomarkers of liverfunction. The blood Cmax following inhaled administration of nintedanibor indolinone or salt thereof, is less than 100.0 ng/mL. The blood Cmaxfollowing administration of nintedanib or indolinone or salt thereof, isless than 10.0 ng/mL, less than 1.0 ng/mL, less than 0.1 ng/mL, lessthan 0.01 ng/mL.

The methods of administering nintedanib or indolinone or salt thereof,include the avoidance of nausea, diarrhea, headaches, leg aches/cramps,fluid retention, visual disturbances, itchy rash, lowered resistance toinfection, bruising or bleeding, loss of appetite, weight gain, reducednumber of blood cells (neutropenia, thrombocytopenia, anemia), headache,edema, congestive cardiac failure observed following oraladministration, comprising administering to said patient inhalednintedanib or indolinone or salt thereof at doses less than 100 mg perday. The nintedanib or indolinone or salt thereof is delivered to thepatient by oral inhalation or intranasal inhalation.

The methods of the invention include daily maximum dosages of less than100 mg per day of nintedanib or salt thereof is delivered to the patientby inhalation. In some embodiments, less than 50 mg, less than 25 mg,less than 10 mg, less than 5 mg, less than 2.5 mg, less than 1 mg, lessthan 0.1 mg, less than 0.05 mg or less than 0.01, less than 0.005, lessthan 0.001 mg per day of nintedanib or indolinone or salt thereof isdelivered to the patient by inhalation once per day, twice per day,three times a day, four times a day, five times a day, six times a dayor greater than six times per day, and may be administered daily, everyother day, every third day, every fourth day, every fifth day, everysixth day or weekly, every other week, every third week or monthly.

The methods of the invention include daily maximum dosages of less than100 mg per day of nintedanib or salt thereof and pirfenidone less than100 mg per day is delivered to the patient by inhalation. In someembodiments, nintedanib or salt thereof is less than 100 mg, less than50 mg, less than 25 mg, less than 10 mg, less than 5 mg, less than 2.5mg, less than 1 mg, less than 0.1 mg, less than 0.05 mg or less than0.01, less than 0.005, less than 0.001 mg per day and pirfenidone isless than 100 mg, less than 50 mg, less than 25 mg, less than 10 mg,less than 5 mg, less than 2.5 mg, less than 1 mg is delivered to thepatient by inhalation once per day, twice per day, three times a day,four times a day, five times a day, six times a day or greater than sixtimes per day, and may be administered daily, every other day, everythird day, every fourth day, every fifth day, every sixth day or weekly,every other week, every third week or monthly.

Methods of treatment include as prophylaxis against interstitial lungdisease (ILD) by administering nintedanib or indolinone or salt thereofto a subject having or suspected to have interstitial lung disease.Interstitial lung disease includes those described above and allconditions of idiopathic interstitial pneumonias as defined by AmericanThoracic Society/European Respiratory Society internationalmultidisciplinary consensus classification of the idiopathicinterstitial pneumonias, AM. J. Respir. Crit. Care Med. 165, 277-304(2002) (incorporated herein by reference).

The therapeutic method may also include a diagnostic step, such asidentifying a subject with or suspected of having ILD. The methodfurther sub-classifies into idiopathic pulmonary fibrosis based onextent of disease, progression of disease, rate of advancement, orresponse to any existing therapy. The delivered amount of aerosolnintedanib or indolinone or salt thereof compound (or salt thereof)formulation is sufficient to provide acute, sub-acute, or chronicsymptomatic relief, slowing of fibrosis progression, halting fibrosisprogression, reversing fibrotic damage, and/or subsequent increase insurvival and/or improved quality of life.

The therapeutic method may also include a diagnostic step of identifyinga subject with or suspected of having fibrosis in other tissues, bynon-limiting example in the heart, liver, kidney or skin and thetherapeutic amount of liquid nebulized, dry powder or metered-doseaerosol nintedanib or indolinone or salt thereof compound is sufficientto provide acute, sub-acute, or chronic symptomatic relief, slowing offibrosis progression, halting fibrosis progression, reversing fibroticdamage, and/or subsequent increase in survival and/or improved qualityof life.

The therapeutic method may also include a diagnostic step identifying asubject with or suspected of having multiple sclerosis and thetherapeutic method comprises administering liquid nebulized, dry powderor metered-dose aerosol nintedanib or indolinone or salt thereofsufficient to provide acute, sub-acute, or chronic symptomatic relief,slowing of demyelination progression, halting demyelination progression,reversing demyelinated damage, and/or subsequent increase in survivaland/or improved quality of life.

Therapeutic treatment methods include administering a therapeuticallyeffective aerosol doses to a patient wherein the dosage is calculated,titrated, or measured to establish or maintain therapeutically effectivethreshold drug concentrations in the lung and/or targeted downstreamtissue, which may be measured as drug levels in epithelial lining fluid(ELF), sputum, lung tissue, bronchial lavage fluid (BAL), or bydeconvolution of blood concentrations through pharmacokinetic analysis.One embodiment includes the use of aerosol administration, deliveringhigh or titrated concentration drug exposure directly to the affectedtissue for treatment of pulmonary fibrosis and inflammation associatedwith ILD (including idiopathic pulmonary fibrosis) in animals andhumans. Peak lung ELF levels achieved following aerosol administrationto the lung will be between 0.01 mg/mL and about 100 mg/mL nintedanib orindolinone or salt thereof or between 0.1 ng/gram lung tissue and about500 mcg/gram lung tissue nintedanib or indolinone or salt thereof.

As a non-limiting example, in a preferred embodiment, a indolinonederivative compound as provided herein (e.g., nintedanib) formulated topermit mist, gas-liquid suspension or liquid nebulized, dry powderand/or metered-dose inhaled aerosol administration to supply effectiveconcentrations or amounts to produce and maintain threshold drugconcentrations in the blood and/or lung, which may be measured as druglevels in epithelial lining fluid (ELF), sputum, lung tissue, bronchiallavage fluid (BAL), or by deconvolution of blood concentrations throughpharmacokinetic analysis that absorb to the pulmonary vasculatureproducing drug levels sufficient for extra-pulmonary therapeutics,maintenance or prophylaxis. Therapeutic treatment methods include theuse of aerosol administration, delivering high concentration drugexposure in the pulmonary vasculature and subsequent tissues andassociated vasculature for treatment, maintenance and/or prophylaxis of,but not limited to cardiac fibrosis, kidney fibrosis, hepatic fibrosis,heart or kidney toxicity, or multiple sclerosis. Peak tissue-specificplasma levels (e.g., heart, kidney and liver) or cerebral spinal fluidlevels (e.g. central nervous system) achieved following aerosoladministration to the lung following oral inhalation or to the lung ornasal cavity following intra-nasal administration will be between 0.0001mcg/mL and about 50 mcg/mL nintedanib or indolinone or salt thereof.Peak lung wet tissue or epithelial lining fluid levels achievedfollowing aerosol administration to the lung are between 0.004 mcg/gramlung tissue or epithelial lining fluid and about 500 mcg/gram lungtissue or epithelial lining fluid nintedanib or indolinone or saltthereof.

Therapeutic methods include acute or prophylactic treatment of a patientthrough non-oral or non-nasal topical administration of nintedanib orindolinone or salt thereof (or a salt thereof) compound formulation toproduce and maintain threshold drug concentrations at a burn site,including the use of aerosol administration, delivering highconcentration drug exposure directly to the affected tissue fortreatment or prevention of scarring in skin.

Therapeutic methods include acute or prophylactic treatment of a patientthrough non-oral or non-nasal topical administration of nintedanib orindolinone or salt thereof compound formulation to produce and maintainthreshold drug concentrations in the eye. One embodiment includes theuse of aerosol administration or formulation drops to deliver highconcentration drug exposure directly to the affected tissue fortreatment or prevention of scarring following surgical glaucoma surgery(e.g., bleb fibrosis). For example according to these and relatedembodiments, the term aerosol may include a spray, mist, or othernucleated liquid or dry powder form. A drop may be simple liquid orsuspension formulation.

As a non-limiting example, an indolinone derivative compound remains atthe therapeutically effective concentration at the site of pulmonarypathology, suspected pulmonary pathology, and/or site of pulmonaryabsorption into the pulmonary vasculature for at least about 10 seconds,at least 1 minute, at least about a 5 minute period, at least about a 10min period, at least about a 20 min period, at least about a 30 minperiod, at least about a 1 hour period, at least a 2 hour period, atleast about a 4 hour period, at least an 8 hour period, at least a 12hour period, at least a 24 hour period, at least a 48 hour period, atleast a 72 hour period, or at least one week. The effective nintedanibor indolinone or salt thereof concentration is sufficient to cause atherapeutic effect and the effect may be localized or broad-acting to orfrom the site of pulmonary pathology.

Delivery sites such as a pulmonary site, nasal cavity or sinus, the annintedanib or indolinone or salt thereof compound formulation asprovided herein is administered in one or more administrations so as toachieve a respirable delivered dose daily of nintedanib or indolinone orsalt thereof of at least about 0.0001 mg to about 100 mg, including allintegral values therein such as 0.0001, 0.001, 0.006, 0.01, 0.02, 0.4,0.6, 0.8, 1, 1.2, 1.4, 1.6, 1.8, 2, 3, 4, 5, 6, 10, 15, 20, 25, 30, 35,40, 45, 50, 60, 70, 80, 90, 100 milligrams.

Delivery sites such as a pulmonary site, nasal cavity or sinus, the annintedanib or indolinone or salt thereof compound formulation asprovided herein is administered in one or more administrations so as toachieve a respirable delivered dose daily of nintedanib or indolinone orsalt thereof of at least about 0.0001 mg to about 100 mg, including allintegral values therein such as 0.0001, 0.001, 0.006, 0.01, 0.02, 0.4,0.6, 0.8, 1, 1.2, 1.4, 1.6, 1.8, 2, 3, 4, 5, 6, 10, 15, 20, 25, 30, 35,40, 45, 50, 60, 70, 80, 90 or 100 milligrams, and pirfenidone orpyridone analog as provided herein is administered in one or moreadministrations so as to achieve a respirable delivered dose daily ofpirfenidone or pyridone analog of at least about 0.0001 mg to about 100mg, including all integral values therein such as 0.0001, 0.001, 0.006,0.01, 0.02, 0.4, 0.6, 0.8, 1, 1.2, 1.4, 1.6, 1.8, 2, 3, 4, 5, 6, 10, 15,20, 25, 30, 35, 40, 45, 50, 60, 70, 80, 90, 100, 200 or 300 milligrams.

In embodiments where a human is mechanically ventilated, aerosoladministration would be performed using an in-line device (bynon-limiting example, the Nektar Aeroneb Pro or PARI eFlow in-linesystem) or similar adaptor with device for liquid nebulization. Aerosoladministration could also be performed using an in-line adaptor for drypowder or metered-dose aerosol generation and delivery.

The methods and the combination of the invention include theadministration of a nintedanib or indolinone salt using a mechanicalventilator wherein an in-line nebulizer is operably connected with theforced air circulation of the ventilator such that an aerosol isgenerated by the nebulizer and administered to a patient connected tothe ventilator such that the breathing support function of theventilator also administers the formulation of the invention describedherein. In in-line nebulizer suitable for use with the invention iscompatible with all ventilator models and is capable of matching theperformance parameters described herein for generating an aerosol misthaving particle size and particle distribution parameters substantiallysimilar to the nebulizers described herein. The in-line nebulizer istypically operated continuously until the equivalent dose as describedherein for a portable nebulizer is delivered.

Alternatively, the admixture of the first solution and the secondsolution, or a suitably formulated dry powder is introduced at a pointin the ventilator air circuitry wherein inspiration by the patient ormovement of air in the ventilator airway advances the admixture into thelungs of the patient. Preferably, the nebulizer is sealed in the airwayto prevent additional airflow from being introduced and to permit acombination of the aerosol mist of the admixture with humidified airgenerated by the ventilator system. In the system described herein,movement of air through the pathway of the ventilator combineshumidified air and the aerosol mist containing the admixture and may betriggered by patient inspiration or as part of a continuous orprogrammed delivery protocol such that the nebulizer is in intermittentor continuous operation during the administration of the admixture. Ineach case, the formation of the aerosol is maintained for a durationadequate to deliver therapeutically effective amounts of the admixturecombination to the lungs of the patient.

Manufacture

The isoform content of the manufactured indolinone derivative compound,most preferably nintedanib may be optimized for drug substance and drugproduct stability, dissolution (in the case of dry powder or suspensionformulations) in the nose and/or lung, tolerability, and site of action(be that lung, nasal/sinus, or regional tissue).

A pharmaceutical composition comprising a therapeutically effectiveamount of an inhaled agent, wherein the agent is nintedanib or saltthereof, wherein the agent is in a particle less than 5 microns in massmean aerodynamic diameter or less than 10 microns volumetric meandiameter wherein the composition, upon inhalation, delivers a dose tothe lung greater than about 0.0001 mg nintedanib or salt thereofcompound per gram of adult human lung tissue, or about 0.0001 mgnintedanib or salt thereof and 0.001 mg pirfenidone or pyridone analogcompound per gram of adult human lung tissue.

The compositions described herein are formulated under or to result inconditions of reduced oxygen. In some embodiments, oxygen is reduced bysparging the formulation diluent prior to addition of the activepharmaceutical ingredient. Sparging gases may be selected from the groupconsisting of carbon dioxide, argon or nitrogen. Oxygen is reduced bysparging the formulation diluent after addition of the activepharmaceutical ingredient. Sparging gases may be selected from the groupconsisting of carbon dioxide, argon or nitrogen. Oxygen exposure isreduced by replacing the ambient gas headspace of the formulationcontainer with an inert gas. Inert gases may be selected from the groupconsisting of argon or nitrogen.

Oxygen exposure is reduced by replacing the ambient gas headspace of theprimary packaging container with an inert gas for example selected fromthe group consisting of argon or nitrogen and combinations thereof,inserting the primary packaging into a gas-impermeable secondarypackaging container,

replacing the ambient gas headspace of the secondary packaging with aninert gas, for example selected from the group consisting of argon ornitrogen and combinations thereof.

To achieve desired nintedanib aqueous concentrations, manufacturingprocess are controlled to enable synthesis of a compound suitable foruse in an aqueous solution for inhalation. The manufacturing processincludes high temperature nintedanib aqueous dissolution, followed byosmolality adjusting agents and/or co-solvent and/or surfactant and/orsalt addition, and subsequent cooling to ambient temperature. In thisprocess, added osmolality adjusting agents and/or co-solvent and/orsurfactant and/or salt stabilize the high-temperature-dissolvednintedanib during the cooling process and provide a stable,high-concentration, ambient-temperature formulation of nintedanib. Theprocessing temperature is 30° C., 35° C., 40° C., 45° C., 50° C., 55°C., 60° C., 65° C., 70° C., 75° C., 80° C., 85° C., 90° C., 95° C., 100°C. or other pressure-enabled increased temperature. The process includesaddition of surfactant and/or osmolality adjusting agents and/orco-solvent and/or salt at the highest temperature or incrementally-lowertemperature as the solution is cooled. Addition of surfactant and/orosmolality adjusting agents and/or co-solvent and/or salt occurs all atonce or incrementally during a maintained temperature or as the solutionis cooled. The time by which the solution is maintained at the highesttemperature is from 0 minutes to 24 hours. The time by which thesolution is cooled from the highest temperature is from 0 minutes to 24hours. The manufacturing process may be shielded from light and thereaction vessel headspace purged with an inert gas such as nitrogen orargon or combinations thereof.

In another embodiment, a kit is provided that includes two containers,each comprising a portion of the pharmaceutical formulation to beadmixed to a final dosing solution comprising an nintedanib orindolinone or salt thereof compound and a nebulizer to generate anaerosol of the pharmaceutical formulation.

Aerosol Dosing

The indolinone derivative compound, most preferably nintedanib asdisclosed herein can be administered at a therapeutically effectivedosage, e.g., a dosage sufficient to provide treatment for the diseasestates previously described. For example, a daily aerosol dose ofnintedanib in a nintedanib compound formulation to a 70 kg human.

The indolinone derivative compound, most preferably nintedanib asdisclosed herein can be administered at a therapeutically effectivedosage, e.g., a dosage sufficient to provide treatment for the diseasestates previously described. In some embodiments, for example, a dailyaerosol dose of nintedanib in an nintedanib compound formulation to a 70kg human may be from about 0.000001 mg to about 4.5 mg nintedanib per kgof body weigh per dose. The amount of active compound administered will,of course, be dependent on the subject and disease state being treated,the severity of the affliction, the manner and schedule ofadministration, the location of the disease (e.g., whether it is desiredto effect intra-nasal or upper airway delivery, pharyngeal or laryngealdelivery, bronchial delivery, pulmonary delivery and/or pulmonarydelivery with subsequent systemic or central nervous system absorption),and the judgment of the prescribing physician; for example, a likelydose range for aerosol administration of nintedanib in preferredembodiments, or in other embodiments of indolinone derivative compoundwould be about 0.0001 mg to 10 mg per dose to about 0.0001 mg to about100 mg per day. Similarly, if pirfenidone or pyridone analog is includedin the formulation, a daily aerosol dose to a 70 kg human may be fromabout 0.01 mg to about 4.5 mg nintedanib per kg of body weigh per dose.A likely dose range for aerosol administration of pirfenidone incombination with nintedanib in preferred embodiments would be about 2.5mg to 50 mg per dose to about 2.5 mg to about 300 mg per day.

Liquid Nebulizer

Previously, two types of nebulizers, jet and ultrasonic, have been shownto be able to produce and deliver aerosol particles having sizes between1 and 5 microns. These particle sizes have been shown as being optimalfor middle airway deposition. However, unless a specially formulatedsolution is used, these nebulizers typically need larger volumes toadminister sufficient amount of drug to obtain a therapeutic effect. Ajet nebulizer utilizes air pressure breakage of an aqueous solution intoaerosol droplets. An ultrasonic nebulizer utilizes shearing of theaqueous solution by a piezoelectric crystal. Typically, however, the jetnebulizers are only about 10% efficient under clinical conditions, whilethe ultrasonic nebulizer is only about 5% efficient. The amount ofpharmaceutical deposited and absorbed in the lungs is thus a fraction ofthe 10% in spite of the large amounts of the drug placed in thenebulizer. The amount of drug that is placed in the nebulizer prior toadministration to the mammal is generally referred to the “nominaldose,” or “loaded dose.” The volume of solution containing the nominaldose is referred to as the “fill volume.” Smaller particle sizes or slowinhalation rates permit deep lung deposition. Both middle-lung andalveolar deposition may be desired for this invention depending on theindication, e.g., middle and/or alveolar deposition for pulmonaryfibrosis and systemic delivery. Exemplary disclosure of compositions andmethods for formulation delivery using nebulizers can be found in, e.g.,US 2006/0276483, including descriptions of techniques, protocols andcharacterization of aerosolized mist delivery using a vibrating meshnebulizer.

Accordingly, a vibrating mesh nebulizer comprising a liquid storagecontainer in fluid contact with a diaphragm and inhalation andexhalation valves is preferably used. In one embodiment, about 0.01 toabout 10 mL of the nintedanib compound formulation (or in anotherrelated embodiment, of a indolinone derivative is placed in thereservoir and the aerosol generator is engaged producing atomizedaerosol of particle sizes selectively between about 1 and about 5micron. In another embodiment, pirfenidone or pyridone analog isincluded.

In some embodiments an nintedanib or indolinone or salt thereof compoundformulation as disclosed herein, is placed in a liquid nebulizationinhaler and prepared in dosages to deliver from about 0.0001 mg to 100mg nintedanib, indolinone derivative compound from a dosing solution ofabout 0.01 mL to about 10 mL with MMAD particles sizes between about 1to about 5 micron being produced. In another embodiment, pirfenidone orpyridone analog is included and delivered from about 2.5 mg to about 100mg pirfenidone or pyridone analog.

The manner in which the first solution and the second solution arecombined to yield an admixture requires only that the solutions arethoroughly mixed. Similarly, where dissolution of a solid in an aqueoussolution is provided, the solution is thoroughly combined with the solidand agitated until no solid precipitate remains. Similarly, thecombination of any two solutions is agitated until no solid precipitateremains. The individual concentrations of the nintedanib or indolinonesalt have been specifically formulated as described herein forsolubility, even though the discovery has been made that many permeantion species that are suitable for enabling tolerability of an inhaledaerosol are incompatible with the active ingredient.

The capability to physically combine the first and the second solutionmay be provided by providing additional space or volume in either of thecontainer holding the first solution or the container holding the secondsolution such that the volume of either solution can be accommodated bythe available volume or headspace of the other container. An additionalcontainer can be used to permit admixture of the first and the secondsolutions, or the two solutions can simply be added directly into thereservoir of the nebulizer and the admixture created by mixing withinthe reservoir. Reference to the containing the admixture in thereservoir of the nebulizer includes the process of forming admixture ofthe first and the second solutions in any container, either inside oroutside of the reservoir of the nebulizer.

In one embodiment of a multi-compartment combination, a container havingsealed compartments such as a blister pack it is used that havesegregated compartments or chambers that contain the first and thesecond solution in a separate, sterile, sealed configurations forindividual placement into the reservoir of a nebulizer or forcombination into an admixture immediately before having the combinedsolutions for containing the admixture within the reservoir of thenebulizer. The individual or multiunit containers may have a pouringfixture, such as of spout or other outflow design that either mates withthe input of the nebulizer reservoir or is conveniently sized so thatthe outflow of the container enables ready insertion of the individualsolutions or the admixture into the nebulizer reservoir. Accordingly, ineither individual or combined format, the containers are shaped to alloweasy dispensing of the individual contents or the admixture. Forinstance, one side of the container may be tapered or have a taperedportion or region through which the content is dispensable into anothervessel upon opening the sealed solution container at a tip or taperedend. Two or more chambers of a container are connected by a channel, thechannel being adapted to direct fluid from the one container having thefirst solution contained therein to the second container, or vice versa,having the other solution and having adequate internal headspace volumeto permit thorough mixing of the two solutions. During storage, theindividual compartments are sealed and closed, but may feature aremovable barrier that is literally removed or broken to permit mixtureof the liquid solutions. A similar configuration is usable where onecomponent is a solid powder or crystalline form and is segregated froman aqueous solution, particularly including dissolved permeant ions.Typically, a channel is closed with a seal that prevents the twosolutions from being combined prior to action by the user. As describedherein, this is an ideal arrangement where individual components of theadmixture are unstable when combined, but may be combined in theadmixture just prior to being contained within the nebulizer.

In another embodiment for multiple-dose separated-compartmentnebulizers, both the solid composition and the liquid solvent areprovided as matched unit doses within multiple containers or withinmultiple chambers of a container. For instance, two-chambered containerscan be used to hold one unit of the solid composition in one of thechambers and one unit of liquid in the other. As used herein, one unitis defined by the amount of drug present in the solid composition, whichis one unit dose. Such two-chambered containers may, however, also beused advantageously for nebulizers containing only one single drug dose.

In one embodiment of a separated-compartment nebulizer, a blister packhaving two blister-type containers may be used, the blistersrepresenting the containers for separating an aqueous solutioncontaining the active ingredient from other osmolality adjusting agentsthat cause instability of the chemical structure of nintedanib orindolinone or salt thereof. The blister pack may be shaped to allow easydispensing of the admixture into the reservoir of the nebulizer. Forinstance, one side of the pack may be tapered or have a tapered portionor region through which the content is dispensable into another vesselupon opening the blister pack at the tapered end. The tapered end mayrepresent a tip.

In one embodiment, a vial or container having two compartments is used,the compartment representing the chambers for containing the solutioncontaining the active ingredient and solution containing osmolalityadjusting agents admixed to prepare a unit dosage of the final liquidcomposition for aerosolization. The first and second liquid compositionsrespectively are preferably contained in matched quantities forpreparing a single unit dosage of the final liquid composition (bynon-limiting example in cases where soluble of the nintedanib orindolinone or salt thereof compound and a osmolality adjusting agentrequired for formulating the desired concentrations of buffer, permeantanion, or other osmolality adjusting agents are unstable for storage,yet all components are desired in the same admixture for administration.

The two compartments are physically separated but in fluid communicationsuch as when the vial or container are connected by a channel orbreakable barrier, the channel or breakable barrier being adapted todirect fluid between the two compartments to enable mixing prior toadministration. During storage, the channel is closed with a seal or thebreakable barrier intact. In this sense, a seal is any structure thatprevents mixing of contents in the two compartments. The seal ispreferably breakable or removable; breaking or removing the seal whenthe nebulizer is to be used will allow the liquid solvent to enter theother chamber and dissolve the solid composition or in the case of twoliquids permit mixing of the two solutions. The dissolution or mixingprocess may be improved by shaking the container.

High Efficiency Liquid Nebulizers

High efficiency liquid nebulizers are inhalation devices that areadapted to deliver a large fraction of a loaded dose to a patient. Somehigh efficiency liquid nebulizers utilize microperforated membranes.High efficiency liquid nebulizers also utilize one or more actively orpassively vibrating microperforated membranes. The high efficiencyliquid nebulizer contains one or more oscillating membranes. The highefficiency liquid nebulizer contains a vibrating mesh or plate withmultiple apertures and optionally a vibration generator with an aerosolmixing chamber. The mixing chamber functions to collect (or stage) theaerosol from the aerosol generator. An inhalation valve is also used toallow an inflow of ambient air into the mixing chamber during aninhalation phase and is closed to prevent escape of the aerosol from themixing chamber during an exhalation phase. The exhalation valve isarranged at a mouthpiece which is removably mounted at the mixingchamber and through which the patient inhales the aerosol from themixing chamber which may operate continuously.

The high efficiency liquid nebulizer may contain a vibratingmicroperforated membrane of tapered nozzles against a bulk liquid thatgenerates a plume of droplets without the need for compressed gas. Inthese designs, a solution in the microperforated membrane nebulizer isin contact with a membrane, the opposite side of which is open to theair. The membrane is perforated by a large number of nozzle orifices ofan atomizing head. An aerosol is created when alternating acousticpressure in the solution is built up in the vicinity of the membranecausing the fluid on the liquid side of the membrane to be emittedthrough the nozzles as uniformly sized droplets.

Some high efficiency liquid nebulizers use passive nozzle membranes anda separate piezoelectric transducer that are in contact with thesolution. In contrast, some high efficiency liquid nebulizers employ anactive nozzle membrane, which uses the acoustic pressure in thenebulizer to generate very fine droplets of solution via the highfrequency vibration of the nozzle membrane.

Some high efficiency liquid nebulizers contain a resonant system. Insome such high efficiency liquid nebulizers, the membrane is driven by afrequency for which the amplitude of the vibrational movement at thecenter of the membrane is particularly large, resulting in a focusedacoustic pressure in the vicinity of the nozzle; the resonant frequencymay be about 100 kHz. A flexible mounting is used to keep unwanted lossof vibrational energy to the mechanical surroundings of the atomizinghead to a minimum. Additional features of a high efficiency liquidnebulizer with perforated membranes are disclosed in U.S. Pat. Nos.6,962,151, 5,152,456, 5,261,601, and 5,518,179, 6,983,747, each of whichis hereby incorporated by reference in its entirety. Other embodimentsof the high efficiency liquid nebulizers contain oscillatable membranes.Features of these high efficiency liquid nebulizers are disclosed inU.S. Pat. Nos. 7,252,085; 7,059, 320; 6,983,747, each of which is herebyincorporated by reference in its entirety.

Commercial high efficiency liquid nebulizers are available from: PARI(Germany) under the trade name eFlow®; Nektar Therapeutics (San Carlos,Calif.) under the trade names AeroNeb® Go and AeroNeb® Pro, and AeroNeb®Solo, Philips (Amsterdam, Netherlands) under the trade names I-Neb®,Omron (Bannockburn, Ill.) under the trade name Micro-Air®, and Activaero(Germany) under the trade name Akita®. Commercial High EfficiencyNebulizers are also available from Aerogen (Galaway, Ireland) utilizingthe OnQ® nebulizer technology, and Pocket Neb from MicroVapor® devices.

Dry Powder Inhaler (DPI)

Based upon allometric scaling of animal efficacy data and humanmodeling, it is observed that the human nintedanib or salt thereof dosemay be as low as a range between about 0.04 mg and about 2.4 mg. Ifclinical observations support these low levels, a dry powder inhaledproduct may be a selected alternative to an aqueous nebulized product.

There are two major designs of dry powder inhalers. One design is themetering device in which a reservoir for the drug is placed within thedevice and the patient adds a dose of the drug into the inhalationchamber. The second is a factory-metered device in which each individualdose has been manufactured in a separate container. Both systems dependupon the formulation of drug into small particles of mass mediandiameters from about 1 to about 5 micron, and usually involveco-formulation with larger excipient particles (typically 100 microndiameter lactose particles). Drug powder is placed into the inhalationchamber (either by device metering or by breakage of a factory-metereddosage) and the inspiratory flow of the patient accelerates the powderout of the device and into the oral cavity. Non-laminar flowcharacteristics of the powder path cause the excipient-drug aggregatesto disperse, and the mass of the large excipient particles causes theirimpaction at the back of the throat, while the smaller drug particlesare deposited deep in the lungs.

As with liquid nebulization and MDIs, particle size of the nintedanib orsalt thereof, or indolinone derivative or salt thereof may be optimizedfor aerosol administration for aerosol administration. If the particlesize is larger than about 5 micron MMAD then the particles are depositedin upper airways. If the aerodynamic particle size of the aerosol issmaller than about 1 micron then it is delivered into the alveoli andmay get transferred into the systemic blood circulation.

By non-limiting example, in dry powder inhalers, the nintedanib or saltthereof, or indolinone derivative or salt thereof disclosed herein areprepared in dosages to disperse and deliver from about 34 mcg to about463 mg from a dry powder formulation.

By non-limiting example, a dry powder nintedanib or salt thereof, orindolinone derivative or salt thereof may be administered in thedescribed respirable delivered dose in 10 or fewer inhalation breaths,or in 8 or fewer inhalation breaths, or in 6 or fewer inhalationbreaths, or in 4 or fewer inhalation breaths, or in 2 or fewerinhalation breaths.

In some embodiments, a dry powder inhaler (DPI) is used to dispense thenintedanib or salt thereof, or indolinone derivative or salt thereofdescribed herein. DPIs contain the drug substance in fine dry particleform. Typically, inhalation by a patient causes the dry particles toform an aerosol cloud that is drawn into the patient's lungs. The finedry drug particles may be produced by any technique known in the art.Some well-known techniques include use of a jet mill or othercomminution equipment, precipitation from saturated or super saturatedsolutions, spray drying, in situ micronization (Hovione), particleengineering (Pulmosphere™, Technosphere®, PRINT®) or supercritical fluidmethods. Typical powder formulations include production of sphericalpellets or adhesive mixtures. In adhesive mixtures, the drug particlesare attached to larger carrier particles, such as lactose monohydrate ofsize about 50 to about 100 microns in diameter. The larger carrierparticles decrease the adhesive forces on the carrier/drug agglomeratesto improve drug dispersion. Turbulence and/or mechanical devices breakthe agglomerates into their constituent parts. The smaller drugparticles are then drawn into the lungs while the larger carrierparticles deposit in the mouth or throat. Some examples of adhesivemixtures are described in U.S. Pat. No. 5,478,578 and PCT PublicationNos. WO 95/11666, WO 87/05213, WO 96/23485, and WO 97/03649, all ofwhich are incorporated by reference in their entirety. Additionalexcipients may also be included with the drug substance. Alternatively,porous particles may be used to deliver the drug without the need of thelarger carrier particles. Such porous particles can be manufacturedusing the Pulmosphere™ or Technosphere® technologies produce particlesthat are large in size but small in density and in aerodynamic diameter.Additionally, making drug particles having a specific shape and sizeusing the PRINT® technology can reduce the dispersion force and enablethe drug particles to be delivered without the use of a carrierexcipient.

There are three common types of DPIs, all of which may be used with thenintedanib or salt thereof, or indolinone derivative or salt thereofcompounds described herein. In a single-dose DPI, a capsule containingone dose of dry drug substance/excipients is loaded into the inhaler.Upon activation, the capsule is breached, allowing the dry powder to bedispersed and inhaled using a dry powder inhaler. To dispense additionaldoses, the old capsule must be removed and an additional capsule loaded.Examples of single-dose DPIs are described in U.S. Pat. Nos. 3,807,400;3,906,950; 3,991,761; and 4,013,075, all of which are herebyincorporated by reference in their entirety. In a multiple unit doseDPI, a package containing multiple single dose compartments is provided.For example, the package may comprise a blister pack, where each blistercompartment contains one dose. Each dose can be dispensed upon breach ofa blister compartment. Any of several arrangements of compartments inthe package can be used. For example, rotary or strip arrangements arecommon. Examples of multiple unit does DPIs are described in EPO PatentApplication Publication Nos. 0211595A2, 0455463A1, and 0467172A1, all ofwhich are hereby incorporated by reference in their entirety. In amulti-dose DPI, a single reservoir of dry powder is used. Mechanisms areprovided that measure out single dose amounts from the reservoir to beaerosolized and inhaled, such as described in U.S. Pat. Nos. 5,829,434;5,437,270; 2,587,215; 5,113,855; 5,840,279; 4,688,218; 4,667,668;5,033,463; and 4,805,811 and PCT Publication No. WO 92/09322, all ofwhich are hereby incorporated by reference in their entirety.

In some embodiments, auxiliary energy in addition to or other than apatient's inhalation may be provided to facilitate operation of a DPI.For example, pressurized air may be provided to aid in powderde-agglomeration, such as described in U.S. Pat. Nos. 3,906,950;5,113,855; 5,388,572; 6,029,662 and PCT Publication Nos. WO 93/12831, WO90/07351, and WO 99/62495, all of which are hereby incorporated byreference in their entirety. Electrically driven impellers may also beprovided, such as described in U.S. Pat. Nos. 3,948,264; 3,971,377;4,147,166; 6,006,747 and PCT Publication No. WO 98/03217, all of whichare hereby incorporated by reference in their entirety. Anothermechanism is an electrically powered tapping piston, such as describedin PCT Publication No. WO 90/13327, which is hereby incorporated byreference in its entirety. Other DPIs use a vibrator, such as describedin U.S. Pat. Nos. 5,694,920 and 6,026,809, both of which are herebyincorporated by reference in their entirety. Finally, a scraper systemmay be employed, such as described in PCT Publication No. WO 93/24165,which is hereby incorporated by reference in its entirety.

Additional examples of DPIs for use herein are described in U.S. Pat.Nos. 4,811,731; 5,113,855; 5,840,279; 3,507,277; 3,669,113; 3,635,219;3,991,761; 4,353,365; 4,889,144, 4,907,538; 5,829,434; 6,681,768;6,561,186; 5,918,594; 6,003,512; 5,775,320; 5,740,794; and 6,626,173,all of which are hereby incorporated by reference in their entirety.

In some embodiments, a spacer or chamber may be used with any of theinhalers described herein to increase the amount of drug substance thatgets absorbed by the patient, such as is described in U.S. Pat. Nos.4,470,412; 4,790,305; 4,926,852; 5,012,803; 5,040,527; 5,024,467;5,816,240; 5,027,806; and 6,026,807, all of which are herebyincorporated by reference in their entirety. For example, a spacer maydelay the time from aerosol production to the time when the aerosolenters a patient's mouth. Such a delay may improve synchronizationbetween the patient's inhalation and the aerosol production. A mask mayalso be incorporated for infants or other patients that have difficultyusing the traditional mouthpiece, such as is described in U.S. Pat. Nos.4,809,692; 4,832,015; 5,012,804; 5,427,089; 5,645,049; and 5,988,160,all of which are hereby incorporated by reference in their entirety.

Dry powder inhalers (DPIs), which involve deaggregation andaerosolization of dry powder particles, normally rely upon a burst ofinspired air that is drawn through the unit to deliver a drug dosage.Such devices are described in, for example, U.S. Pat. No. 4,807,814,which is directed to a pneumatic powder ejector having a suction stageand an injection stage; SU 628930 (Abstract), describing a hand-heldpowder disperser having an axial air flow tube; Fox et al., Powder andBulk Engineering, pages 33-36 (March 1988), describing a venturi eductorhaving an axial air inlet tube upstream of a venturi restriction; EP 347779, describing a hand-held powder disperser having a collapsibleexpansion chamber, and U.S. Pat. No. 5,785,049, directed to dry powderdelivery devices for drugs.

Commercial examples of capsule-based or blister pack-based dry powderinhalers that can be used with the nintedanib or salt thereof, orindolinone derivative or salt thereof formulations described hereininclude the Aerohaler, Aerolizer, Aspirair, Breezehaler, DiskhalerForspiro, Gyrohaler, Plastiaphe Monodose, Podhaler, Prohaler, Redihaler,Rotahaler, Turbohaler, Handihaler and Discus. Multi dose reservoirdevices include E Flex, Jethaler, NEXThaler, Novolizer, PADD, Pulmojet,Spiromax, Swinghaler, Turbuhaler and Ultrahaler.

Pharmacokinetics

Inhalation therapy of aerosolized nintedanib or a indolinone derivativecompound enables direct deposition of the sustained-release or activesubstance in the respiratory tract (be that intra-nasal or pulmonary)for therapeutic action at that site of deposition or systemic absorptionto regions immediately down stream of the vascular absorption site. Inthe case of central nervous system (CNS) deposition, intra-nasalinhalation aerosol delivery deposits nintedanib or a indolinonederivative compound directly upstream of the CNS compartment.

Similar to the intra-nasal and pulmonary applications described above,treatment or prevention of organs outside the respiratory tract requiresabsorption to the systemic vascular department for transport to theseextra-respiratory sites. In the case of treating or preventing fibroticor inflammatory diseases associated with the heart, liver and kidney,deposition of drug in the respiratory tract, more specifically the deeplung will enable direct access to these organs through the left atriumto either the carotid arteries or coronary arteries. Similarly, in thecase of treating CNS disorder (e.g., multiple sclerosis), deposition ofdrug in the respiratory tract (as defined above) or nasal cavity, morespecifically the absorption from the nasal cavity to the nasal capillarybeds for immediate access to the brain and CNS. This direct deliverywill permit direct dosing of high concentration nintedanib or aindolinone derivative compound in the absence of unnecessary systemicexposure. Similarly, this route permits titration of the dose to a levelfor these indications.

Pharmacokinetics is concerned with the uptake, distribution, metabolismand excretion of a drug substance. A pharmacokinetic profile comprisesone or more biological measurements designed to measure the absorption,distribution, metabolism and excretion of a drug substance. One way ofvisualizing a pharmacokinetic profile is by means of a blood plasmaconcentration curve, which is a graph depicting mean active ingredientblood plasma concentration on the Y-axis and time (usually in hours) onthe X-axis. Some pharmacokinetic parameters that may be visualized bymeans of a blood plasma concentration curve include:

-   -   1) Cmax: The maximum plasma concentration in a patient;    -   2) AUC: area under the curve    -   3) TOE: time of exposure    -   4) T½: period of time it takes for the amount in a patient of        drug to decrease by half    -   5) Tmax: The time to reach maximum plasma concentration in a        patient

Pharmacokinetics (PK) is concerned with the time course of a therapeuticagent, such as nintedanib or a indolinone derivative compoundconcentration in the body. Pharmacodynamics (PD) is concerned with therelationship between pharmacokinetics and efficacy in vivo. PK/PDparameters correlate the therapeutic agent, such as exposure withefficacious activity. Accordingly, to predict the therapeutic efficacyof a therapeutic agent, such as with diverse mechanisms of actiondifferent PK/PD parameters may be used.

As used herein, the “peak period” of a pharmaceutical's in vivoconcentration is defined as that time of the pharmaceutical dosinginterval when the pharmaceutical concentration is not less than 50% ofits maximum plasma or site-of-disease concentration. “Peak period” isused to describe an interval of nintedanib or a indolinone derivativecompound dosing. When considering treatment of lung diseases, a methodor system described herein provides at least a two-fold enhancement inpharmacokinetic profile for treatment of the lung disease. The methodsand systems described herein provide at least a two-fold enhancement inthe lung tissue pharmacokinetic profile of nintedanib or indolinone orsalt thereof compound as compared to oral administration.

The amount of nintedanib or indolinone or salt thereof compound that isadministered to a human by inhalation may be calculated by measuring theamount of nintedanib or indolinone or salt thereof compound andassociated metabolites that are found in the urine. About80% ofadministered nintedanib is excreted in the urine. The calculation basedon compound and metabolites in urine may be done through a 48 hour urinecollection (following a single administration), whereby the total amountof nintedanib or indolinone or salt thereof compound delivered to thehuman is the sum of measured nintedanib and its metabolites. Bynon-limiting example, knowing that 80% of nintedanib is excreted, a 50mg sum urinary measurement of nintedanib and its metabolites wouldtranslate to a delivered dose of about 63 mg (50 mg divided by 80%). Ifthe inhaled aerosol fine-particle fraction (FPF) is 75%, one may assumethat about 75% of the drug deposited in the lung (and about 25% wasswallowed, and subsequently absorbed from the gut with 80% excreted inthe urine). Integrating these two calculations, of a 63 mg delivereddose (as measured by urinary excretion), about 47 mg would be the amountof inhaled aerosol nintedanib delivered to the lung (the actual RDD;calculated as the product of 63 mg and a 75% FPF). This RDD can then beused in a variety of calculations, including lung tissue concentration.

The lung tissue Cmax and/or AUC of nintedanib or indolinone or saltthereof, that is obtained after administration of a single inhaled doseto the mammal is about the same or greater than the lung tissue Cmaxand/or AUC of nintedanib or indolinone or salt thereof, that is obtainedafter a single dose of orally administered dose that is from about 80%to about 120% of the inhaled dose; and/or the plasma Cmax and/or AUCthat is obtained after administration of a single inhaled dose to themammal is less than the plasma Cmax and/or AUC of obtained after asingle dose of orally administered nintedanib or indolinone or saltthereof, at a dose that is from about 80% to about 120% of the inhaleddose. The lung tissue Cmax that is obtained after administration of asingle inhaled dose to the mammal is greater than the lung tissueobtained after a single dose of orally administered nintedanib orindolinone or salt thereof, at a dose that is from about 80% to about120% of the inhaled dose. The lung tissue AUC of nintedanib orindolinone or salt thereof, that is obtained after administration of asingle inhaled dose to the mammal is greater than the lung tissue AUCobtained after a single dose of orally administered nintedanib orindolinone or salt thereof, at a dose that is from about 80% to about120% of the inhaled dose. The plasma Cmax of nintedanib or indolinone orsalt thereof, that is obtained after administration of a single inhaleddose to the mammal is less than the plasma Cmax obtained after a singledose of orally administered nintedanib or indolinone or salt thereof, ata dose that is from about 80% to about 120% of the inhaled dose. Theplasma AUC of nintedanib or indolinone or salt thereof, that is obtainedafter administration a single inhaled dose to the mammal is less thanthe plasma AUC obtained after a single dose of orally administerednintedanib or indolinone or salt thereof, compound at a dose that isfrom about 80% to about 120% of the inhaled dose.

In one aspect, described herein is a method of achieving a lung tissueCmax of nintedanib or indolinone or salt thereof compound that is atleast 1.5 times, at least 2 times, at least 3 times, at least 4 times,at least 5 times, at least 6 times, at least 1.5 times, at least 1.5times, at least 1.5 times, at least 1.5 times, at least 7 times, atleast 8 times, at least 9 times, at least 10 times, at least 20 times aCmax of up to 200 mg of an orally administered dosage of nintedanib orindolinone or salt thereof, the method comprising nebulizing an aqueoussolution comprising nintedanib or indolinone or salt thereof, andadministering the nebulized aqueous solution to a human Described hereinis a method of achieving a lung tissue Cmax of nintedanib or indolinoneor salt thereof compound that is at least equivalent to or greater thana Cmax of up to 200 mg of an orally administered dosage of nintedanib orindolinone or salt thereof, the method comprising nebulizing an aqueoussolution comprising nintedanib or indolinone or salt thereof, andadministering the nebulized aqueous solution to a human.

In one aspect, described herein is a method of achieving a lung tissueAUC₀₋₂₄ of nintedanib or indolinone or salt thereof, that is at least1.5 times, at least 2 times, at least 3 times, at least 4 times, atleast 5 times, at least 6 times, at least 1.5 times, at least 1.5 times,at least 1.5 times, at least 1.5 times, at least 7 times, at least 8times, at least 9 times, at least 10 times, at least 1.5-20 times, atleast 1.5-15 times, at least 1.5-10 times, at least 1.5-5 times, or atleast 1.5-3 times AUC₀₋₂₄ of up to 200 mg of an orally administereddosage, the method comprising nebulizing an aqueous solution comprisingnintedanib or indolinone or salt thereof compound and administering thenebulized aqueous solution to a human. A method of achieving a lungtissue AUC₀₋₂₄ of nintedanib or indolinone or salt thereof compound thatis at least equivalent to or greater than AUC₀₋₂₄ of up to 600 mg of anorally administered dosage of nintedanib or indolinone or salt thereof,the method comprising nebulizing an aqueous solution comprisingnintedanib or indolinone or salt thereof and administering the nebulizedaqueous solution to a human.

The methods include a method of administering nintedanib or indolinoneor salt thereof, to a human, comprising administering a nebulizedaqueous solution containing the nintedanib or indolinone or saltthereof, wherein the lung tissue Cmax achieved with the nebulizedsolution is at least 1.5 times, at least 2 times, at least 3 times, atleast 4 times, at least 5 times, at least 6 times, at least 1.5 times,at least 1.5 times, at least 1.5 times, at least 1.5 times, at least 7times, at least 8 times, at least 9 times, at least 10 times, at least20 times the lung tissue Cmax achieved with an orally administerednintedanib or indolinone or salt thereof, dosage that is from 80% to120% of the dose amount of nintedanib that is administered bynebulization.

The methods include a method of administering nintedanib or indolinoneor salt thereof, to a human, comprising administering a nebulizedaqueous solution containing the nintedanib or indolinone or saltthereof, wherein the lung tissue Cmax achieved with the nebulizedsolution is at least equivalent to or greater than the lung tissue Cmaxachieved with an orally administered nintedanib or indolinone or saltthereof, dosage that is from 80% to 120% of the dosage of nintedanib orindolinone or salt thereof, in the nebulized aqueous solution ofnintedanib or indolinone or salt thereof that is administered.

The methods include a method of administering nintedanib or indolinoneor salt thereof, to a human, comprising administering a nebulizedaqueous solution containing the nintedanib or indolinone or saltthereof, wherein the plasma AUC₀₋₂₄ achieved with the nebulized solutionis less than the plasma AUC₀₋₂₄ achieved with an orally administerednintedanib or indolinone or salt thereof, dosage that is from 80% to120% of the dosage of nintedanib or indolinone or salt thereof, in thenebulized aqueous solution of nintedanib or indolinone or salt thereof,that is administered.

The methods include a method of administering nintedanib or indolinoneor salt thereof comprising administering a nebulized aqueous solutioncontaining the nintedanib or indolinone or salt thereof, wherein thelung tissue AUC₀₋₂₄ achieved with the nebulized solution is at least 1.5times, at least 2 times, at least 3 times, at least 4 times, at least 5times, at least 6 times, at least 1.5 times, at least 1.5 times, atleast 1.5 times, at least 1.5 times, at least 7 times, at least 8 times,at least 9 times, at least 10 times, at least 1.5-20 times, at least1.5-15 times, at least 1.5-10 times, at least 1.5-5 times, or at least1.5-3 times the lung tissue AUC₀₋₂₄ achieved with an orally administerednintedanib or indolinone or salt thereof compound dosage that is from80% to 120% of the dosage of nintedanib or indolinone or salt thereof,in the nebulized aqueous solution of nintedanib or indolinone or saltthereof. The methods include a method of administering nintedanib orindolinone or salt thereof, to a human, comprising administering anebulized aqueous solution containing the nintedanib or indolinone orsalt thereof, wherein the lung tissue AUC₀₋₂₄ achieved with thenebulized solution is at least 1.5 times the lung tissue AUC₀₋₂₄achieved with an orally administered nintedanib or indolinone or saltthereof, dosage that is from 80% to 120% of the dosage of nintedanib orindolinone or salt thereof, in the nebulized aqueous solution ofnintedanib or indolinone or salt thereof compound.

The methods include a method of improving the pharmacokinetic profileobtained in a human following a single oral dose administration ofnintedanib or indolinone or salt thereof. The single oral dose comprisesup to about 200 mg of nintedanib or indolinone or salt thereof. Themethod of improving the pharmacokinetic profile further comprises acomparison of the pharmacokinetic parameters following inhalationadministration to the same parameters obtained following oraladministration and may require multiple measurements of a single patientover time comparing the pharmacokinetic parameters in a single patientvarying by dosage, route of administration, form of activepharmaceutical ingredient and other parameters as described herein. Aprolonged improvement in pharmacokinetic profile is obtained by repeatedand frequent administrations of the aqueous solution of nintedanib orindolinone or salt thereof, as described herein by inhalation. Repeatedadministration of nintedanib or indolinone or salt thereof, byinhalation provides more frequent direct lung exposure benefitting thehuman through repeat high Cmax levels. The inhaled nintedanib orindolinone or salt thereof, doses are administered once a day, twice aday, three times a day, four time a day, every other day, twice a week,three times a week, four times a week, five times a week, six times aweek, seven times a week, or any combination thereof.

Small intratracheal aerosol doses deliver a rapidly-eliminated high lungCmax and low AUC. Human, animal and in vitro studies all indicate thatnintedanib efficacy is dose responsive (i.e. larger doses correlate withimproved efficacy) and suggest Cmax is a key driver in nintedanibefficacy. While lung Cmax appears important for efficacy, more regularnintedanib exposure is important to enhance this effect. In the contextof treating lung diseases in a human, more frequent direct-lungadministration of nintedanib or indolinone or salt thereof compound mayprovide benefit through both repeat high Cmax dosing and providing moreregular exposure of the active therapeutic agent.

Methods of treatment include a method for the treatment of lung diseasein a mammal comprising administering directly to the lungs of the mammalin need thereof nintedanib or salt thereof, or a indolinone derivativecompound or salt thereof, on a continuous dosing schedule, wherein theobserved lung tissue Cmax of a dose of nintedanib or indolinonederivative or salt thereof greater than 0.1, 1.0, 10, 100, or 1000,ng/mL lung epithelial lining fluid. The observed lung tissue Cmax from adose of nintedanib or salt thereof, or a indolinone derivative compoundor salt thereof, is greater than 10, 50, 100, 150, 200, 250, 300, 350,400, 450, 500, 750, or 1000 mcg/mL lung epithelial lining fluid.

Methods of Dosing and Treatment Regimens

The term “continuous dosing schedule” refers to the administration of aparticular therapeutic agent at regular intervals. Continuous dosingschedule refers to the administration of a particular therapeutic agentat regular intervals without any drug holidays from the particulartherapeutic agent. Continuous dosing schedule refers to theadministration of a particular therapeutic agent in alternating cyclesof drug administration followed by a drug holiday (e.g. wash out period)from the particular therapeutic agent. For example, in some embodimentsthe therapeutic agent is administered once a day, twice a day, threetimes a day, once a week, twice a week, three times a week, four times aweek, five times a week, six times a week, seven times a week, everyother day, every third day, every fourth day, daily for a week followedby a week of no administration of the therapeutic agent, daily for a twoweeks followed by one or two weeks of no administration of thetherapeutic agent, daily for three weeks followed by one, two or threeweeks of no administration of the therapeutic agent, daily for fourweeks followed by one, two, three or four weeks of no administration ofthe therapeutic agent, weekly administration of the therapeutic agentfollowed by a week of no administration of the therapeutic agent, orbiweekly administration of the therapeutic agent followed by two weeksof no administration of the therapeutic agent. [Is this still a“continuous dosing schedule” if there are weekly breaks?]

The amount of nintedanib or a indolinone derivative compound isadministered once-a-day. In some other embodiments, the amount ofnintedanib or a indolinone derivative compound is administeredtwice-a-day. In some other embodiments, the amount of nintedanib or aindolinone derivative compound is administered three times a day.

Where improvement in the status of the disease or condition in the humanis not observed, the daily dose of nintedanib or a indolinone derivativecompound is increased for example, a once-a-day dosing schedule ischanged to a twice-a-day dosing schedule. a three times a day dosingschedule is employed to increase the amount of nintedanib or aindolinone derivative compound that is administered. Frequency ofadministration by inhalation is increased in order to provide repeathigh Cmax levels on a more regular basis. The frequency ofadministration by inhalation is increased in order to provide maintainedor more regular exposure to Nintedanib The frequency of administrationby inhalation is increased in order to provide repeat high Cmax levelson a more regular basis and provide maintained or more regular exposureto nintedanib.

The amount of repeat high Cmax dosing providing more regular exposure ofthe active therapeutic agent that is given to the human varies dependingupon factors such as, but not limited to, condition and severity of thedisease or condition, and the identity (e.g., weight) of the human, andthe particular additional therapeutic agents that are administered (ifapplicable).

EXAMPLES Example 1. Compound Screening Platform

Each of the active ingredients described herein are susceptible of minorchemical structural modifications or alternative molecular compoundingthat do not affect the utility for the purposes described herein.Although the following description is exemplified by nintedanib salts,alternative forms of nintedanib or other indolinones can be screened forefficacy as follows.

Rat and human derived pulmonary tissue were cut in pieces and placed ona polystyrene petri dish containing antibiotics/antimycotics and LG DMEM10% FBS 1% P/S media. Cells are expanded in LG DMEM 10% FBS 1% P/S mediauntil an appropriate number of cells are available. All experiments willbe performed before passage 10. Expanded rat and human pulmonaryfibroblasts are trypsinized and plated in 6-well plates containing acoverslip, attachment factor and media followed by overnight incubation.After incubation, media is changed to 1% FBS LG DMEM. Fibroblast tomyofibroblast diffe review for your review small rentiation and orproliferation is induced with 2.5 to 10 ng/mL active tumor growth factorbeta 1 (TGF-beta1). The kinetics of differentiated myofibroblastappearance is measured by assessing incubated cells at 12, 24, 36, 48and 72 hours post-TGF-beta1 induction. Each cell condition is performedin triplicate. At each time point, cells are fixed usingparaformaldehyde and stained for F-actin, DAPI, and alpha-SMA (formyofibroblast formation). Proliferation is quantified microscopically.This method may employ difference cell lines such as pulmonary arterialsmooth muscle cells and/or may be induced by other cytokines, such asplatelet-derived growth factor (PDGF). After processing cells forimmunohistochemistry, cells will be imaged using an Olympus 1×-81fluorescent microscope and analyzed using Metamorph Premier software.

To assess the effect of a target compound on fibroblast proliferation,differentiation and/or collagen production, potential therapeutics maybe added at the same time, prior to or after addition of TGFβ, PDGF orother inducing cytokine. Non-limiting examples of potential therapeuticagents include all those listed herein. Moreover, addition of potentialtherapeutic may be done to mimic a drugs in vivo pharmacokineticprofile. By example, an orally-administered drug for a pulmonaryindication would have a characteristic vascular and pulmonary absorptionphase, Cmax, Tmax, AUC and elimination half-life. By comparison, aninhaled drug may exhibit pharmacokinetic characteristics that differfrom the oral route. By example, inhalation may deliver a higher lungCmax, more rapid lung Tmax, higher lung AUC, be rapidly eliminated fromthe lung and/or may result in less residual drug. By non-limitingexample, to employ the assay described herein, an oral drug underconsideration for inhaled aerosol delivery may be exposed to fibroblastsor other cell type in the presence of TGF-beta (or other cytokine) usingthat drug's real or estimated oral pharmacokinetic profile. Separatelyor in parallel, in a separate set of wells expose the same cell type inthe presence of TGF-beta (or other cytokine) using that drugs real orestimated inhaled pharmacokinetic profile. This may be accomplished bytime-course dilution or addition of the potential therapeutic. Moreover,this assay may be used to mimic repetitive TGF-beta or other cytokineexposure and/or therapeutic regimen (by example once a day, twice a dayor three times a day) to assess the effect this may have on the drugsanti-proliferative, anti-differentiation, anti-collagen productionand/or other measurable endpoint. By non-limiting example, markers offibroblast activation, proliferation and/or myofibroblastdifferentiation and collagen production may include alpha-SMA, SMAD,GAPDH, HSP47, pro-collagen, markers of endoplasmic reticulum un-foldedprotein response (UPR, e.g., GRP78) and many others. Detection of thesecomponents may be by Western and Northern blot analysis, microscopy,phosphorylation signaling, gene and protein array technology, andmetagenomic analysis.

In addition to identifying individual forms of an active ingredient thatinterfere with fibroblast proliferation, differentiation andmyofibroblast collage production, this assay may also be employed toassess the effect of combinations of active ingredient and differingsalt forms. Further, through some active ingredient formulations havedifferent targets, this and variations of this assay may be used todissect the role of different targets in fibrosis formation and thefibrotic disease, stroma formation and/or stroma-associated metastaticprocesses.

Example 2. PDGF-Induced Fibroblast Proliferation

The impact of nintedanib on inhibiting PDGF-induced fibroblastproliferation was determined in primary human fibroblasts. Briefly,fibroblasts were seeded at 2,500 cells/well in 96-well flat clear bottomFalcon plates in 10% FBS F12/DMEM Media with 1% Pen/Strep. These cellswere left in a 37 degree incubator (5% CO₂) for 24 hours to allow thecells to adhere to the plate. The media was then removed, washed withPBS and replaced the media with 0.5% FBS F12/DMEM Media with 1%Pen/Strep for another 24 hours. To characterize the impact exposureduration of each drug on inhibiting proliferation, cells were pretreatedwith or without drug (0.5 to 50 nM) for 30 minutes, washed and eitherreplaced with 0.5% FBS F12/DMEM media with 1% Pen/Strep +/−20 ng/mLPDGF-BB (short-duration drug exposure mimicking pulmonary inhalationpharmacokinetics) or 0.5% FBS F12/DMEM media with 1% Pen/Strep +/−20ng/mL PDGF-BB and the initial drug concentration (long duration drugexposure mimicking oral pharmacokinetics). After 72 hours of viablecells was assessed using the MTS assay. Drug concentrations tested werenot cytotoxic (data not shown).

TABLE 1 Impact of nintedanib and exposure duration on PDGF-inducedfibroblast differentiation. Nintedanib Exposure Nintedanib ShortDuration Long Duration nM Proliferation* SEM Proliferation* SEM 0 0.1600.080 0.160 0.065 0.5 0.115 0.070 0.003 0.095 5.0 0.011 0.185 −0.3590.120 50.0 −0.175 0.047 −0.642 0.068 *Relative proliferation

Results from Table 1 show that nintedanib is dose-responsive ininhibiting PDGF-induced fibroblast proliferation. The data also showthat only short-term nintedanib exposure is required for this activitywith a fifty-percent inhibitory concentration (IC50) of about 3 nM(about 1.6 ng/mL).

Example 3. Salt Screen Determination for Nintedanib

XRPD analysis was carried out on a PANalytical X'pert pro, scanning thesamples between 3 and 35° 2θ. The material was gently compressed andloaded onto a multi-well plate with Kapton or Mylar polymer film tosupport the sample. The multi-well plate was then placed into thediffractometer and analyzed using Cu K radiation (α1 λ=1.54060 Å;α2=1.54443 Å; β=1.39225 Å; α1: α2 ratio=0.5) running in transmissionmode (step size 0.0130° 2θ) using 40 kV/40 mA generator settings.

Polarized Light Microscopy (PLM). The presence of crystallinity(birefringence) was determined using an Olympus BX50 polarizingmicroscope, equipped with a Motic camera and image capture software(Motic Images Plus 2.0). All images were recorded using the 20×objective, unless otherwise stated.

Thermogravimetric Analysis (TGA). Approximately, 5 mg of material wasweighed into an open aluminum pan and loaded into a simultaneousthermogravimetric/differential thermal analyzer (TG/DTA) and held atroom temperature. The sample was then heated at a rate of 10° C./minfrom 20° C. to 300° C. during which time the change in sample weight wasrecorded along with any differential thermal events (DTA). Nitrogen wasused as the purge gas, at a flow rate of 300 cm3/min.

Differential Scanning calorimetry (DSC). Approximately, 5 mg of materialwas weighed into an aluminum DSC pan and sealed non-hermetically with apierced aluminum lid. The sample pan was then loaded into a SeikoDSC6200 (equipped with a cooler) cooled and held at 20° C. Once a stableheat-flow response was obtained, the sample and reference were heated to275° C. at scan rate of 10° C./min and the resulting heat flow responsemonitored. Nitrogen was used as the purge gas, at a flow rate of 50cm3/min.

Infrared spectroscopy (IR) was carried out on a Bruker ALPHA Pspectrometer. Sufficient material was placed onto the center of theplate of the spectrometer and the spectra were obtained using thefollowing parameters: Resolution: 4 cm−1; Background Scan Time:16 scans;Sample Scan Time: 16 scans; Data Collection: 4000 to 400 cm−1; ResultSpectrum: Transmittance Software: OPUS version 6

Nuclear Magnetic Resonance (NMR). NMR experiments were performed on aBruker AVIIIHD spectrometer equipped with a DCH cryoprobe operating at500.12 MHz for protons. Experiments were performed in deuterated DMSOand each sample was prepared to ca. 10 mM concentration.

Dynamic Vapour Sorption (DVS). Approximately, 10 mg of sample was placedinto a mesh vapour sorption balance pan and loaded into a DVS-1 or DVSAdvantage dynamic vapour sorption balance by Surface MeasurementSystems. The sample was subjected to a ramping profile from 40-90%relative humidity (RH) at 10% increments, maintaining the sample at eachstep until a stable weight had been achieved (dm/dt 0.004%, minimum steplength 30 minutes, maximum step length 500 minutes) at 25° C. Aftercompletion of the sorption cycle, the sample was dried using the sameprocedure to 0% RH and then a second sorption cycle back to 40% RH. Twocycles were performed. The weight change during the sorption/desorptioncycles were plotted, allowing for the hygroscopic nature of the sampleto be determined. XRPD analysis was then carried out on any solidretained.

High Performance Liquid Chromatography-Ultraviolet Detection (HPLC-UV):Instrument: Dionex Ultimate 3000; Column: Acquity CSH C18 100 mm×2.1 mm1.7 μm; Column Temperature: 50° C.; Autosampler Temperature: Ambient; UVwavelength: 210 nm; Injection Volume: 4 μL; Flow Rate: 0.6 mL/min;Mobile Phase A: 0.1% formic acid in water; Mobile Phase B: 0.1% formicacid in acetonitrile. The HPLC method used the gradient in Table 2.

TABLE 2 Gradient program: Time (minutes) Solvent B [%] 0 10 1 10 15 6016 60 16.1 10 20 10

Mass Spectrometry: Instrument: LCQ Ion Trap Mass Spectrometer usingAgilent 1100; Column: ACE Excel 3 C18, 3.0 μm, 75 mm×4.6 mm; MobilePhase A: 0.1% formic acid in deionized water; Mobile Phase B: 0.1%formic acid in acetonitrile; Diluent: Acetonitrile:water 50:50; FlowRate: 1.0 mL/min; Runtime: 20 mins; Column Temperature: 30° C.;Injection Volume: 10 μL; PDA Range: 190-400 nm; Scan: +ve 100.0-2000.0m/z, −ve 100.0-2000.0 m/z. The MS method used the gradient in Table 3.

TABLE 3 Gradient program: Time (minutes) Solvent B [%] 0.00 5 12.00 9515.00 95 15.10 5 20.00 5

Initial Characterization: Nintedanib was characterized by XRPD, PLM,TG/DTA, DSC, DVS, NMR, UPLC and HPLC-MS.

pka measurement was carried out using UV-metric triple titration usingmethanol as co-solvent and pH-metric techniques also by triple titrationusing methanol as co-solvent.

Solvent Solubility: Approximately 10 mg of Nintedanib was weighed into24 vials and a known volume aliquot (50 μL) of the appropriate solventwas added until dissolution was observed or 100 volumes of solvent hadbeen added. Between each addition, the mixture was checked fordissolution and where no dissolution was apparent, the mixture washeated to ca. 40° C. and checked again. Samples where the materialdissolved, were left to evaporate. Any solids produced from evaporationsamples were analyzed by XRPD in order to assess the polymorphic form.

The solvent systems used during the solvent solubility screen, togetherwith the corresponding ICH Class, are detailed in Table 4.

TABLE 4 Solvents selected for solubility screen ICH Number Solvent Class1 1-Butanol 3 2 1-Propanol 3 3 2-Propanol 3 4 40% Methanol: 60% Water (%v/v) (calc. a_(w) 0.8) N/A 5 50% 2-Propanol: 50% Water (% v/v) (calc.a_(w) 0.8) N/A 6 Acetone 3 7 Acetonitrile 2 8 Anisole 3 9Dichloromethane 2 10 Dimethylsulfoxide 3 11 Ethanol 3 12 Ethyl Acetate 313 Ethyl Ether 3 14 Heptane 3 15 Isopropyl Acetate 3 16 Methanol 2 17Methylethyl Ketone 3 18 Methylisobutyl Ketone 2 19N,N′-Dimethylacetamide 2 20 n-Hexane 3 21 tert-Butylmethyl Ether 3 22THF 2 23 Toluene 2 24 Water N/A

Primary Salt Screening. The 17 counterions shown in Table were selectedfor salt screening, pirfenidone was also screened and a controlexperiment with Nintedanib only. The solvent systems shown in Table wereselected for salt screening. For sulfonic acids MEK was used instead ofmethanol and acetone:water 50:50 (v/v) was used instead of IPA:water toavoid any potential genotoxic impurities. Ca. 40 mg of Nintedanib wasslurried in 300 μL of solvent and mixed with 1.05 equivalent of acid,dissolved/slurried in 200-300 μL of the allocated solvent. If the acidwas insoluble in the selected solvent, a slurry was used. If the acidwas a liquid it was added to the API slurry from a stock solution in theallocated solvent. The mixtures of API/counterion/solvent weretemperature cycled between ambient and 40° C. in 4 hour cycles for ca. 3days. Any solids present were isolated and allowed to dry at ambientconditions, for ca. 30 minutes prior to analysis by XRPD. Wheresolutions were obtained they were evaporated to obtain solid material.Every potential salt that yielded sufficient material was analyzed byXRPD, TG/DTA, NMR and stored at 40° C./75% RH for ca. 72 h thenre-analyzed by XRPD.

TABLE 5 Counterions selected for salt screening Acid pKa1 pKa2 pKa3 HBr−9.00 HCl −6.10 Sulfuric acid −3.00 1.92 Methanesulfonic acid −1.20Saccharin 1.6 Hydroxyethanesulfonic 1.66 acid L-Aspartic acid 1.88 3.65Maleic acid 1.92 6.23 Phosphoric acid 1.96 7.12 12.32 EDTA 2 2.7 6.2L-Glutamic acid 2.19 4.25 L-Tartaric acid 3.02 4.36 Fumaric acid 3.034.38 Citric acid 3.13 4.76 6.40 DL-Lactic acid 3.86 L-Ascorbic acid 4.1711.57 Acetic acid 4.76

TABLE 6 Solvent systems selected for salt screening Approximate Color ofICH Solubility Solution/ Solvent Class (mg/mL) Slurry Pattern 1Dichloromethane 2  17 yellow 2 2 THF 2 <10 yellow 2 3 N,N′- 2  26 yellow3 Dimethylacetamide 4 Methanol 2  <11* yellow 1 (input) 5 Acetone 3 <10yellow 1 (input) 6 50% 2-Propanol: 50% N/A <10 yellow 1 (input) Water (%v/v) (calc. aw 0.8)

Initial Characterization. The received material (batch: FM341441402 5 g)was characterized, with the following results observed: XRPD analysisshowed Nintedanib to be crystalline and will be referred to as Pattern1; PLM analysis showed birefringent plate-like particles of varioussizes; TGA showed a loss of 1.41% between ca. 25-120° C. This loss inmass is likely a result of unbound solvent loss. The DTA trace showed asingle endotherm with onset ca. 254° C., likely due to melting; DSCanalysis showed a single endotherm with onset ca. 253° C., indicatingthat pattern 1 is a pure form with a single melting event observed; DVSanalysis showed Nintedanib to be slightly hygroscopic with ca. 1.7% massuptake at 90% RH. The kinetics showed no evidence of recrystallization,but in the second cycle it was noted that the balance was noisier. PostDVS the material was found to remain Pattern 1, with an additional peakobserved ca. 12.7° 2θ, the peaks were generally also observed to besharper; 1H NMR spectroscopy corresponded with the structure ofNintedanib; HPLC average purity was measured to be 99.9%; and LC-MSanalysis measured 540.3 m/z ([M+H]+) using positive ionization modewhich corresponds with the expected mass of 539.636 Da.

Solvent Solubility Screen. The results from the solvent solubilityscreen are shown in Table 7. Solubility of ≥17 mg/mL was observed for 2of the 24 solvent systems. The majority of the experiments showedsolubility less than 10 mg/mL and most isolated solids produced Pattern1 of the free base. Two new patterns of the free base were alsoproduced. Pattern 2 was observed from DCM and THF and Pattern 3 wasobserved from DMA.

TABLE 7 Solubility Screen Results. Approximate Color of ICH SolubilitySolution/Slurry Solvent Class (mg/mL) Liquid Pattern 1 1-Butanol 3 <10yellow 1 2 1-Propanol 3 <10 yellow 1 3 2-Propanol 3 <11 yellow 1 4 40%Methanol:60% N/A <10 pale yellow 1 Water (% v/v) (calc. aw 0.8) 5 50%2-Propanol: N/A <10 yellow 1 50% Water (% v/v) (calc. aw 0.8) 6 Acetone3 <10 yellow 1 7 Acetonitrile 2 <10 yellow 1 8 Anisole 3 <10 yellow 1 9Dichloromethane 2  17 yellow 2 10 Dimethylsulfoxide 3  <10* yellowSolution 11 Ethanol 3 <10 yellow 1 12 Ethyl Acetate 3 <10 yellow 1 13Ethyl Ether 3 <10 pale yellow 1 14 Heptane 3 <10 colorless 1 15Isopropyl Acetate 3 <10 yellow 1 16 Methanol 2  <11* yellow 1 17Methylethyl Ketone 3 <10 yellow 1 18 Methylisobutyl 2 <10 yellow 1Ketone 19 N,N′- 2  26 yellow 3 Dimethylacetamide 20 n-Hexane 3 <10colorless 1 21 tert-Butylmethyl 3 <11 yellow 1 Ether 22 THF 2 <10 yellow3 23 Toluene 2 <10 yellow 1 24 Water N/A <10 colorless 1

Primary Salt Screening. The results from the primary salt screen areshown in Table 8. Potential salts were observed for 15 of the 17counterions tested. Nintedanib freebase patterns were obtained forpirfenidone experiments which indicated that no salt or co-crystalformation was successful.

TABLE 8 Primary Salt Screen Results Solvent IPA:water Methanol 50:50(MEK for (acetone:water sulfonic 50:50 for DCM THF DMA acids) Acetonesulfonic acids) Counterion Pattern (notes) HBr 5 4 3 2 1 5 HCl 2(FB) 1 32 1 1 Sulfuric acid 4 1 3 2 1 3 Methanesulfonic acid 1 1 2 1 1 (GL)Hydroxyethanesulfonic acid 2(FB) 2 1 2 2 2 L-Aspartic acid 2(FB) 3(FB)3(FB) 1(FB) 1(FB) 1 Maleic acid 1 1 2 1 1 1(FB) Phosphoric acid 2(FB)3(FB) 2 2(+Ukn) 2 1 L-Glutamic acid 3(FB) 3(FB) 3(FB) 1(FB) 1(FB) 1(FB)L-Tartaric acid 1, 2(FB) 1 3(FB) 1 1, 2(FB) 1(+Ukn) Fumaric acid 2 2 22(+Ukn) 2 1 Citric acid 2(FB, AC) 1(3; FB) 3(FB) 1(+Ukn) 1 2 DL-Lacticacid 2, 3(FB) 1(3; FB) 3(FB) 2 1 2 L-Ascorbic acid 3(FB) 2, 3(FB) 3(FB)1(FB) 1(FB) 1(FB) Acetic acid 2 3(FB) 3(FB) 1(FB) 1 2 Saccharin 1 1 NS 21 2 EDTA 2(FB) 2(FB) 3(FB) 1(FB) 1(FB) 1 Pirfenidone 2(FB) 3(FB) 3(FB)1(FB) 1(FB) 1(FB) Potential Salt FB: Freebase AC: Acid counterion NS: Nosolid obtained Ukn: Unknown GL: Gel-like material, solution at 40° C.

Potential salts were stored at 40° C./75% RH for ca. 3 days and analyzedby XRPD, the results are summarized Table 9.

TABLE 9 Pattern Stability Screen 72 hrs 72 hrs 72 hrs 72 hrs 72 hrs 40°C./ 40° C./ 40° C./ 40° C./ 40° C./ 75% 75% 75% 75% 75% CounterionInitial RH Initial RH Initial RH Initial RH Initial RH HBr 1 1 2 2 3 3 44 5 5 HCl 1 1 2 2 3 1 Sulfuric acid 1 1 2 1 3 3 4 3 MSA 1 1 2 1 HESA 1 22 2 L-Aspartic 1 1 acid Maleic acid 1 1 2 2 Phosphoric 1 1 2 2 acidL-Tartaric 1 1 acid Fumaric acid 1 1 2 2(MU) Citric acid 1 1 2 2(MU)DL-Lactic 1 1 2 2 acid Acetic acid 1 1(FB) 2 1 Saccharin 1 2 2 2 EDTA 11(MU) MSA: Methanesulfonic acid HESA: Hydroxyethanesulfonic acidUnchanged pattern FB: Freebase MR: Mainly unchanged pattern

Secondary HCl Salt Screen:

XRPD analysis showed that Pattern 1 of the HCl salt appeared to besuccessfully scaled-up after temperature cycling for 72 h andre-slurrying in acetone with additional temperature cycling for 24 h.The pattern produced contained less peaks than the Pattern 1 materialproduced in the primary salt screen. [is a conclusion possible here?]The other form in the mixture from the primary screen appears to be thatproduced when the HCl salt was prepared on a 5 g scale.

The first post-slurry diffractogram showed the presence of free base.The material was re-slurried after 72 h due to solvent evaporationoccurring during cycling and to therefore ensure that salt formation wascompleted. PLM analysis particles with no clearly defined morphologywith birefringence observed under polarized light. TGA showed a weightloss of 4.41% between ca. 25-60° C. (likely due to loss of water from amonohydrate plus some possible surface-bound moisture loss) and afurther loss of 4.03% between ca. 175-250° C. (likely associated withdegradation). DTA showed endotherms with onsets ca. 50° C., 183° C. and273° C. associated with these losses in mass and degradation,respectively. Material likely a monohydrate. In the primary screen theinitial weight loss was only 2.3% and the further loss was 0.7%,endotherm ca. 183° C. not observed in primary screen.

DVS analysis showed the input material to contain ca. 5.4% (likelywater) showing ca. 2.2% uptake from the input material at 90% RH on thefirst cycle, showing the HCl salt to be hygroscopic—loss of ca. 4% waterbelow 10% RH supports the idea that the material is a monohydrate. Thesample re-hydrated on the second sorption step whilst also uptaking whatappeared to be further surface bound water. No evidence ofre-crystallization was observed during the analysis. Post-DVS XRPDanalysis showed the HCl salt to remain unchanged.

NMR analysis showed the salt to be consistent with the primary screen,0.04 eq. of acetone observed and peak shifting was observed comparedwith the free base and a broad water peak, indicating salt formation.

CAD analysis for counterion content measured 1.35 eq. of chloride. Thisindicates that the material is a monosalt. A hydrated form slightlyincreases the % recovery of chloride detected.

FT-IR appeared to be consistent with the structure. 7 day stabilitytesting at 40° C/75% RH, 80° C. and ambient light showed the salt toremain pattern 1. The material was physically stable to changes intemperature and humidity when stored for one week. Purity of thesematerials remained unchanged as shown in Table 10.

TABLE 10 Purity results for stability testing for HCl salt Purity (%)Input Ambient 80° C. 40° C./75% RH 99.9 99.9 99.9 99.9

Table 11 shows the measured pH values for disproportionation/hydrationexperiments. The acetone:water samples were observed to be solutionsafter 24 h, the disproportionation sample in water was observed to bemostly dissolved resulting in a slightly turbid solution. No XRPD datacould be compiled on the hydration or disproportionation of the salt dueto the high solubility in water and acetone/water mixtures.

TABLE 11 Measured pH values for disproportionation/hydration studiesWater Volume of water (μL) in 5 mL pH Pre- pH Post- Activity of AcetoneAgitation Agitation 0.3 30 1.94 2.45 0.6 205 2.32 2.33 0.9 2900 1.892.24 1.0 5000 2.05 2.33

Secondary Phosphate Salt Screen:

The phosphate scale-up attempt appeared to produce mostly free basematerial after 24 h thermal cycling. Slurrying for 72 h produced apattern containing free base and an unknown pattern. Some solventevaporation was observed post-thermal cycle. The material wasre-slurried in more solvent for a further 24 h as the lack of Pattern 2reproduction may have been a solubility issue. Pattern 2 was notproduced and some peaks of the free base were still visible in thediffractogram produced. A further 0.5 equiv. of acid was added to ensurecomplete salt formation and therefore eliminate the presence offreebase. Pattern 2 was not reproduced. Additional peaks were observedat 4, 5 and 6° 2θ, which could not be attributed to freebase. Thematerial obtained was assigned as Pattern 3.

Small agglomerated particles were observed by PLM with birefringenceobserved under polarized light.

TGA showed a loss of 1.26% between ca. 25-60° C., likely unboundsolvent, with a loss of 2.70% between ca. 60-200° C., likely due tobound solvent. Pattern 3 is possibly a hydrated form. An endotherm wasobserved with onset ca. 32° C. (associated with the first weight loss),multiple events observed upon degradation.

DVS analysis showed the input material to contain ca. 4.1% likely watershowing a further ca. 10.6% uptake from input material at 90% RH,showing the phosphate salt to be hygroscopic. No evidence ofre-crystallization was observed during the analysis. Post-DVS XRPDanalysis showed the phosphate salt to produce a similar pattern butdecrease in crystallinity.

1H NMR analysis showed the salt to be consistent with the primaryscreen, 0.7 eq. of acetone observed, salt formation was shown by peakshifting compared to the freebase. 31P NMR analysis showed the salt tobe a bis-phosphate salt.

FT-IR appeared to be consistent with the structure.

XRPD analysis showed the phosphate salt to remain Pattern 3 afterstorage at 80° C. and ambient conditions. A new, poorly crystallinepattern was produced when stored at 40° C./75% RH—Pattern 4. Purityanalysis of these materials (Table showed a slight decrease at 40°C./75% RH and ambient and a slightly larger decrease at 80° C. but notany significant reduction in purity was noted.

TABLE 12 Purity results for stability testing for phosphate salt Purity(%) Input Ambient 80° C. 40° C./75% RH 99.9 99.6 99.2 99.8

Table shows the measured pH values for disproportionation/hydrationexperiments. The 0.3 and 0.6 aw samples were observed to be mostlydissolved resulting in slightly turbid solutions after 24 h, 0.9 and 1aw were observed to be thin slurries.

TABLE 13 Measured pH values for disproportionation/hydration studiesWater Volume of water (μL) in pH Pre- pH Post- Activity 5 mL of AcetoneAgitation Agitation 0.3 30 3.08 2.68 0.6 205 2.60 2.52 0.9 2900 2.342.35 1.0 5000 2.75 1.78

Secondary HBr Salt Screen:

XRPD analysis showed that Pattern 1 of the HBr salt appeared to besuccessfully scaled-up after temperature cycling for 72 h.

PLM analysis showed particles with no clearly defined morphology withbirefringence observed under polarized light.

TGA showed a weight loss of 0.1% between ca. 25-180° C., likely due tothe loss of unbound acetone. DTA showed an endotherm with onset ca. 263°C., due to melting. In the primary screen an initial weight loss of0.81% was observed, the primary screen sample was not dried undervacuum.

DSC analysis showed an endotherm with onset ca. 260° C., due to melting.

DVS analysis showed the input material to contain ca. 1.0% (likelywater) with a ca. 4.5% uptake from the input material at 90% RH observedon the first cycle, showing the HCl salt to be hygroscopic. No evidenceof re-crystallization was observed during the analysis. Post-DVS XRPDanalysis showed the HBr salt to remain unchanged.

NMR analysis showed the salt to be consistent with the primary screen.Around 0.04 eq. of acetone was observed in the sample. Peak shifting wasobserved compared with the free base along with a broad water peak, bothindicating salt formation.

CAD analysis for counterion content measured eq. of bromide

FT-IR appeared to be consistent with the structure.

7 day stability testing showed the salt to remain Pattern 1 at 80° C.and ambient light and to be a mixture of Pattern 1 and 4 at 40° C./75%RH. Purity of these materials remained unchanged (as shown in Table)apart from the sample stored at ambient light, where a 0.5% drop inpurity was observed.

TABLE 14 Purity results for stability testing for HBr salt Purity (%)Input Ambient 80° C. 40° C./75% RH 99.7 99.2 99.6 99.7

Table shows the measured pH values for disproportionation/hydrationexperiments. The salt only remained Pattern 1 at 0.3 aw. New patterns 6and 7 are likely hydrated due to the high water activity conditions forproduction.

TABLE 15 Measured pH values for disproportionation/hydration studiesWater pH Pre- Activity Agitation Pattern 0.3 4.84 1 0.6 5.38 4 0.9 5.56New pattern (Pattern 6) 1 2.27 New pattern (Pattern 7)

Solubility Assessment of HCl and Phosphate Salt in Water. Dissolutionwas observed for the HCl salt after 1.8 mL of deionized water was addedto 20 mg of salt; giving ca. 11 mg/mL solubility. See Table for pHmeasurements, over time the pH values were observed to remain fairlyconstant. Dissolution was not observed for the phosphate salt after 2 mLof water was added; giving solubility <10 mg/mL. After ca. 6 h and 18 hof agitation the pH was re-measured. The HCl sample remained a solutionand the phosphate salt a slurry.

TABLE 16 pH measurements for HCl salt solubility assessment Salt InitialpH pH at 6 h pH at 18 h HCl 2.22 2.26 2.08 Phosphate 3.43 3.00 2.11

Aqueous Solubility Measurement for Primary Screen Samples. The aqueoussolubility measurement results are shown in Table 17.

TABLE 17 Aqueous solubility measurement Salt Pattern Solubility pH HBr 1~5 mg/mL 3.95 (heated to 40° C.), precipitation observed after 24 hFumarate 1 <0.625 mg/mL 6.41 Citrate 1 <0.625 mg/mL 3.74 Tartrate 1<0.625 mg/mL 5.22 Lactate 1  0.625 mg/mL 4.74 Acetate 1 <0.625 mg/mL5.24 Saccharin 2 <0.625 5.51 Edetate 1 ~5 mg/mL, viscous solution, 3.31gel formed on standing for ~72 h

Water pH Titration. The pH upon cooling for 2 mg/mL Nintedanib slurryHCl sample was measured to be 4.76, the concentration of the filteredsample was measured to be 1.7 mg/mL by HPLC.

For the HCl salt solution prepared at 1.7 mg/mL Nintedanib the pH priorto filtration was 4.75 and 4.88 post filtration.

The results from adjusting the pH are shown in Table . After 1 week thesample was observed to remain clear.

TABLE 18 Water pH titration results Acid/Base Volume Added Added (μL) pHObservations N/A N/A 4.75 Initial pH N/A N/A 4.88 Post-filtration NaOH10  5.12 Slightly turbid solution HCl 5 4.38 Transparent solution NaOH 54.85 Initial increase in turbidity which cleared NaOH 5 5.72 Initialincrease in turbidity which cleared N/A N/A 5.30 Slightly turbidsolution after 1 h HCl 5 4.74 Transparent solution N/A N/A 4.78Transparent solution after 1 h N/A N/A 4.88 Clear, 1 week at ambienttemperature

Table shows the 0.5 mg/mL results for HBr water titration and Table forHCl water titration using 5 g batch. Both samples were observed toremain in solution after 1 week.

TABLE 19 Water pH titration results for HBr salt Acid/Base Volume AddedAdded (μL) pH Observations N/A N/A 6.01 Slightly turbid N/A N/A 6.63Filtered initially clear, slightly turbid for pH measurement N/A N/A6.71 Clear, filtered HCl 10  3.85 Clear NaOH 5 4.21 Clear NaOH 5 5.07Slightly turbid HCl 5 4.83 Clear N/A N/A 5.51 Clear, 1 h at ambienttemperature N/A N/A 6.36 Clear, 1 week at ambient temperature

TABLE 20 Water pH titration results for HCl salt (5 g batch) Acid/BaseVolume Added Added (μL) pH Observations N/A N/A 6.17 Slightly turbid N/AN/A 6.31 Initially clear, slightly turbid for pH measurement N/A N/A6.74 Clear, filtered HCl 10  3.76 Clear NaOH 5 4.37 Clear NaOH 5 5.05Slightly turbid HCl 5 4.81 Clear N/A N/A 5.58 Clear, 1 h at ambienttemperature N/A N/A 5.62 Clear, 1 week at ambient temperature

Citrate Buffer Formulation. The attempt to solubilize the HCl salt in pH4.75 citrate buffer at a concentration of ˜1.7 mg/mL (Nintedanib) wasunsuccessful. When aliquots of salt were added to the buffer (withstirring), full dissolution was not observed after stirring at ambienttemperature for 30 min.

The attempt to solubilize the HBr and HCl salts in pH 4.8 buffer at ca.0.5 mg/mL (Nintedanib) was also unsuccessful. pH measurements are shownin Table 21.

TABLE 21 pH measurements for 0.5 mg/mL citrate buffer experiments SaltInitial pH pH 1 h HBr 4.83 4.82 HCl 4.84 4.80

0.5 mg/mL Solubility Assessment. Table 22 shows the results for thefiltered and unfiltered experiments. The HBr salt gave 94% concentrationfor filtered sample compared to unfiltered and 99% for HCl salt. Theresults show that the insoluble component is likely unreacted freebase,which appears to have lower aqueous solubility than the salts.

TABLE 22 0.5 mg/mL experiment results Filtered Unfiltered ConcentrationConcentration Salt pH (mg/mL) pH (mg/mL) HBr 5.31 0.4644 5.12 0.4965 HCl5.36 0.4797 5.28 0.4850

The received Nintedanib freebase was found to be crystalline, with meltca. 253° C. and to be slightly hygroscopic with 99.9% purity by HPLC.Solubility of the Nintedanib freebase was found to be ≥17 mg/mL for 2 ofthe 24 solvent systems, with the majority of solvent systems testedshowing low solubility.

Salt formation was successful with 15 of the 17 counterions tested inthe primary screen. From the successful salts produced in the primaryscreen, Pattern 1 HCl salt was scaled-up on a 500 mg scale in acetone.However, it became apparent as additional data was collected thatPattern 1 was possibly a mixture of two forms. The first of the twoforms were produced in the initial scale-up of the HCl salt and wasfound to be a mono-hydrate. The second of the two forms were producedwhen the material was scaled-up to produce 5 g of HCl salt. Thismaterial was found to be a potentially anhydrous form based on thethermal data. Pattern 2 of the phosphate salt was not able to beprepared, however Pattern 3 bis-phosphate salt was produced instead andcharacterized. Pattern 1 of the HBr salt was successfully reproduced ona 500 mg scale. The mono-hydrated form of the HCl salt was found to be amore developable than the phosphate salt, due to more favorable thermalproperties, significantly less hygroscopicity than the phosphate saltand remaining unchanged under stability testing. In general, the HBrsalt Pattern 1 was found to be more developable compared to thephosphate salt mainly due to lower hygroscopicity, but the mono-hydratedform of the HCl salt was found to be more developable than the HBr saltdue to better stability. An attempt to produce Pattern 1 HCl salt wasalso prepared on 5 g scale, however this resulted in a potentiallyanhydrous material. Along with a polymorphism study of the HCl salt,recommended further work would include full characterization on morepotentially suitable salts in order to locate other suitable salts withthe desired aqueous solubility and citrate buffer stability. Potentialsalts that could be considered for further analysis are fumarate Pattern1, tartrate Pattern 1 and citrate Pattern 1. A summary of threenintedanib salt forms is described in Table 23 below.

TABLE 23 Initially Selected Nintedanib Salt Summary Salt HCl PhosphateHBr XRPD Pattern Mono-hydrated form 3 (2 not produced) 1 present in 1Solvent Used In Acetone Acetone Acetone Production Equiv. of Acid Added1.05 1.05 1.05 Melt Onset from 273 (possible ~210 (steady loss in 263(possible TG/DTA (° C.) degradation from 183° C. mass from the outset)degradation from onwards) 220° C. onwards) Hygroscopicity Contained 5.4%and a Contained 4.1% and a Contained 1.0% and further 2.2% uptake upfurther 10.6% uptake up further 4.5% uptake up to 90% RH to 90% RH to90% RH Hygroscopic Hygroscopic Hygroscopic Post-DVS Pattern unchangedPattern 3 produced with Pattern 1 remained, no decreased crystallinityevidence of form and additional peaks change Stability: Ambient Patternretained under Pattern 3 remained Pattern 1 remained temperature &light, all conditions under ambient under ambient light humidityconditions and 80° C. and 80° C., 40° C./75% RH and Pattern 4 producedat 40° C./ 40° C./75% RH observed 80° C. sealed vial (1 75% RH to bemixture of pattern week) 1 and 4 Salt Stoichiometry Mono Bis MonoHydration Solution obtained, Insufficient material for Pattern 1observed at presence of hydrated XRPD analysis, 0.3 a_(w), pattern 4 at0.6 material not able to be presence of hydrated a_(w) and a new patternat determined at low, material not able to be 0.9 a_(w). No hydrationmedium and high water determined at low, observed at low water activitydue to high medium and high water activity. Pattern 4 solubilityactivity due to high (likely hydrated) at solubility medium wateractivity. New likely hydrated form (Pattern 6) at high water activity.

Solid state and chemical stability of nintedanib HBr and nintedanib HClsalts at 25C/60% RH and 40C/75% RH has been tested through 6 months.Pattern 1 of the HCl salt and pattern 1 of the HBr salt were tested.Table 24 and Table 25 summarize the total impurities (by HPLC),polymorphic form (by X-ray powder diffraction) and, where applicable,weight loss (by TGA/DSC) for both the HCl and HBr salt forms. Both saltforms showed negligible change in total impurities through 6 months atboth storage conditions. While the HCl salt form remained as pattern 1through 6 months at both storage condition, the HBr salt stored at40C/75% RH condition slowly converted to pattern 4. There were nochanges in polymorphic form for both salt forms stored at 25C/60% RHcondition.

TABLE 24 Stability of nintedanib HBr and nintedanib HCl salt forms at25° C./60% RH Test Attribute Initial 1 week 4 weeks 2 months 6 monthsNintedanib HBr salt Total 0.29% 0.40% 0.33% 0.42% 0.47% impuritiesPolymorphic Pattern 1 Pattern 1 Pattern 1 Pattern 1 Pattern 1 formWeight loss^(a) 0.23% Not required Not required Not required Notrequired Nintedanib HCl salt Total 0.29% 0.41% 0.36% 0.36% 0.46%impurities Polymorphic Pattern 1 Pattern 1 Pattern 1 Pattern 1 Pattern 1form Weight loss^(a) 0.82% Not required Not required Not required Notrequired ^(a)Except for the initial time point, testing is conductedonly when there is a polymorphic change

TABLE 25 Stability of nintedanib HBr and nintedanib HCl salt forms at40° C./75% RH Test Attribute Initial 1 week 4 weeks 2 months 6 monthsNintedanib HBr salt Total 0.29% 0.43% 0.34% 0.41% 0.44% impuritiesPolymorphic Pattern 1 Pattern 1 Pattern 1 & Pattern 4 Pattern 4 formPattern 4 Weight loss^(a) 0.23% Not required 1.33% 4.12% 3.72%Nintedanib HCl salt Total 0.29% 0.39% 0.34% 0.37% 0.52% impuritiesPolymorphic Pattern 1 Pattern 1 Pattern 1 Pattern 1 Pattern 1 formWeight loss^(a) 0.82% Not required Not required Not required Notrequired ^(a)Except for the initial time point, testing is conductedonly when there is a polymorphic change

Process development of the nintedanib HBr salt was conducted atlaboratory scales (˜25 g) under various conditions to evaluate processreproducibility and to optimize the process. Table 26 shows thenintedanib HBr polymorphic forms obtained and the apparent solubility ofeach. During this process, a new polymorphic form was identified(pattern X)

TABLE 26 Polymorphic Forms of Various Nintedanib HBr Laboratory ScaleBatches Apparent Solubility Batch Number Polymorph (mg/mL) AP036 Pattern1 0.97 AP069 Pattern 4 1.02 AP143 Pattern 4 0.96 AP018 Pattern X 2.04AP064 Pattern X 1.96 AP152 Pattern X 1.95 AP177w Pattern 3 1.03 AP177dPattern X 2.05 AP178w Pattern 3 1.01 AP178d Pattern X 1.94

Table 27 provides the characteristic peaks (2θ and relative peakintensity) of patterns 1, 3, 4 and X of nintedanib HBr Salt and pattern1 of nintedanib HCl salt.

TABLE 27 Nintedanib salt 2θ and relative peak intensity Nintedanib HBrNintedanib HCl Pattern 1 Pattern 3 Pattern 4 Pattern X Pattern 1Relative Relative Relative Relative Relative Intensity IntensityIntensity Intensity Intensity 2θ (%) 2θ (%) 2θ (%) 2θ (%) 2θ (%) 6.0 8.99.0 3.6 8.7 35.9 6.1 9.5 3.4 7.5 8.9 21.4 9.5 6.9 9.3 0.7 7.5 3.0 6.087.3 9.2 5.3 9.9 26.8 10.6 1.9 9.5 12.7 8.8 10.0 11.1 15.6 14.2 24.711.4 7.1 9.8 14.4 9.1 7.1 11.3 4.3 14.3 27.3 12.0 6.4 12.0 2.9 10.9 12.912.0 28.4 14.4 27.2 13.0 8.6 12.3 9.5 11.3 8.3 13.7 13.6 14.6 7.5 13.44.5 14.2 25.5 12.1 93.9 14.3 2.4 15.7 6.4 14.4 2.7 14.6 24.0 12.6 6.515.3 21.4 15.8 5.2 15.2 2.0 15.3 2.8 13.8 25.0 17.0 55.5 16.5 6.9 15.716.0 16.0 15.0 15.2 10.4 17.3 12.8 18.7 5.1 16.6 2.7 16.4 7.1 16.6 19.617.6 48.9 19.0 10.4 16.8 6.1 16.6 8.4 16.9 79.0 18.0 26.3 19.7 16.1 17.4100.0 18.4 37.9 17.5 54.5 18.4 22.4 19.8 38.3 18.2 4.0 19.2 8.9 17.644.0 18.8 50.9 20.2 8.6 18.6 2.9 19.7 100.0 17.9 17.2 19.1 28.4 20.617.3 18.9 5.1 20.1 4.2 18.3 52.9 20.0 6.2 20.8 20.8 19.2 3.0 20.6 27.318.5 60.9 20.3 59.4 21.5 16.2 19.6 6.4 21.1 12.4 18.6 59.0 20.8 12.821.8 12.9 20.3 12.7 21.4 22.1 19.1 39.7 21.2 32.1 21.9 10.7 21.4 22.321.7 17.9 19.8 6.7 21.6 100.0 22.4 15.3 21.8 73.2 22.3 37.7 20.4 50.122.1 74.3 22.5 20.0 22.3 8.1 23.2 27.3 20.6 35.1 22.5 16.8 23.0 7.1 22.734.1 23.8 20.9 21.2 100.0 22.9 63.3 23.4 100.0 22.9 7.4 24.3 29.0 22.065.3 23.2 17.0 23.4 42.3 23.2 5.3 24.7 9.6 22.5 36.7 24.0 56.7 23.8 11.223.8 5.3 25.6 12.9 22.9 61.4 25.1 14.3 24.0 12.2 24.1 11.5 26.1 10.923.2 15.3 25.5 8.6 24.4 17.0 24.6 15.3 27.0 27.5 23.9 19.9 26.2 12.524.4 14.2 25.5 11.2 28.0 4.4 24.2 18.1 27.3 9.4 28.2 7.3 25.9 5.3 28.26.8 25.3 9.4 27.6 17.8 28.4 10.4 26.5 10.2 28.6 4.4 26.2 10.6 27.8 51.928.8 6.4 26.9 5.4 28.9 12.5 27.4 7.1 28.8 12.2 29.5 11.0 27.2 2.7 29.511.6 27.8 12.1 29.3 38.3 29.9 8.4 27.9 9.9 29.9 6.5 28.3 32.6 29.6 11.230.0 6.7 28.5 13.0 29.2 47.5 31.9 13.1 28.8 15.3 30.2 6.2 34.5 7.6 32.28.1 34.3 12.2

The solubility of Pattern 4 and Pattern X at various pH values weredetermined by UV/vis spectrophotometry. Excess Pattern 4 and Pattern XHBr salts were added to distilled water, vortexed at high speed and thepH was adjusted to the target value by adding 1N HCl or 1N NaOH. Thetest solutions were mixed on a magnetic stirrer for over 48 hours, thenfiltered through a 0.22 μm nylon membrane syringe filter and analyzed byuv/vis spectrophotometry at 390 nm. Table 28 shows the solubility ofpattern 4 and pattern X as a function of pH. The solubility of bothpolymorphic forms decreases with increasing pH. Both polymorphic formshave similar solubility profile.

TABLE 28 pH-Solubility of Nintedanib HBr Salt Pattern 4 and Pattern X pHNintedanib HBr Pattern 4 Nintedanib HBr Pattern X 3.1 2.01 1.86 3.9 1.471.72 4.4 Not measured 1.49 4.7 1.38 Not measured 5.1 Not measured 1.405.3 1.07 Not measured

The temperature-solubility profiles of nintedanib HBr Pattern 4 andPattern X were determined by adding excess nintedanib HBr to distilledwater, vortexed at high speed and kept in a refrigerator at 5° C.,ambient room temperature at 22° C., and in a stability chamber at 40° C.for over 48 hours. During this time period, the samples wereperiodically taken out of the storage, vortexed, and returned to storagecondition. At the end of the incubation period, the test solutions werefiltered through a 0.22 μm nylon membrane syringe filter and analyzed byuv/vis spectrophotometry (at 390 nm) for drug concentration. Table 29summarizes the solubility of both salt forms as a function oftemperature. The solubility of both polymorphic forms increases withincreasing temperature. Both polymorphic forms have similar solubilityprofiles.

TABLE 29 Temperature-Solubility of Nintedanib HBr Pattern 4 and PatternX Nintedanib HBr Solubility (mg/mL) Storage Condition Pattern 4 PatternX  5° C. 0.79 0.65 22° C. 1.38 1.49 40° C. 3.20 3.41

The process to salt nintedanib base into nintedanib hydrobromide, XRPDPattern 4 is as follows. Listed volumes may be scaled proportionately.To a flask is charged methyl(Z)-3-(((4-(N-methyl-2-(4-methylpiperazin-1-yl)acetamido)phenyllamino)(phenyl)methylene)-2-oxoindoline-6-carboxylate(10 g, 18.53 mmol). At 20 Celsius, acetone (90 ml, 9 vol) and water (40ml, 4 vol) are charged in the flask and the mixture is stirred (200rpm). The mixture is heated in a glycol bath to 50 Celsius. HBr (48%aq., 2.2 ml, 19.31 mmol) is charged in a single portion. The solution isfiltered to a second flask and cooled at a rate of 1 Celsius/min toabout 33 Celsius, over which time about 5% XRPD Pattern 4 seed wasslowly added. At about 33 Celsius, the remainder of the seed is addedand temperature maintained for 1 additional hour. The mixture is thencooled from about 33 Celsius to 0 Celsius over 3 hours with a linearcooling profile. The mixture is then stirred at 0 Celsius for 1 hour.The solids are isolated by filtration on a sintered funnel. The isolatedsolids are washed with acetone (2×20 ml, 2×2 vol), then vacuum dried for5 minutes. The solid is dried in a vacuum oven overnight (40 Celsius,16-18 hours) to obtain Nintedanib hydrobromide, XRPD Pattern 4.

The process to salt nintedanib base into nintedanib hydrobromide, XRPDPattern X is as follows. Listed volumes may be scaled proportionately.To a flask is charged methyl(Z)-3-(((4-(N-methyl-2-(4-methylpiperazin-1-yl)acetamido)phenyl)amino)(phenyl)methylene)-2-oxoindoline-6-carboxylate (10 g, 18.53 mmol). At 20Celsius, acetone (90 ml, 9 vol) and water (40 ml, 4 vol) are charged inthe flask and the mixture is stirred (200 rpm). The mixture is heated ina glycol bath to 50 Celsius. HBr (48% aq., 2.2 ml, 19.31 mmol) ischarged in a single portion. The solution is filtered to a second flaskand cooled at a rate of 1 Celsius/min to about 33 Celsius, over whichtime about 5% XRPD Pattern X seed was slowly added. At about 33 Celsius,the remainder of the seed is added and temperature maintained for 1additional hour. The mixture is then cooled from about 33 Celsius to 0Celsius over 3 hours with a linear cooling profile. The mixture is thenstirred at 0 Celsius for 1 hour. The solids are isolated by filtrationon a sintered funnel. The isolated solids are washed with acetone (2×20ml, 2×2 vol), then vacuum dried for 5 minutes. The solid is dried in avacuum oven overnight (40 Celsius, 16-18 hours) to obtain Nintedanibhydrobromide, XRPD Pattern X.

Example 4: Formulations

TABLE 30 Exemplary Nintedanib Formulations Nintedanib Salt, NintedanibHCl or Propylene Sodium Sodium Lysinate/N-acetylcysteine FormulationNintedanib HBr (mg/mL)^(a) Glycol (%) Chloride (mM) Bromide (mM) SodiumSaccharin (mM) Buffer (mM) 1 1.875 1.875 0 0 0 0 2 0.625 1.875 0 0 0 0 30.1 1.875 0 0 0 0 4 0.01 1.875 0 0 0 0 5 1.875 1.875 0 0 0 1 6 0.6251.875 0 0 0 1 7 0.1 1.875 0 0 0 1 8 0.01 1.875 0 0 0 1 9 1.875 1.875 0 00 0 10 0.625 1.875 0 0 0 0 11 0.1 1.875 0 0 0 0 12 0.01 1.875 0 0 0 0 131.875 1.875 0 0 0 0 14 0.625 1.875 0 0 0 0 15 0.1 1.875 0 0 0 0 16 0.011.875 0 0 0 0 17 1.875 1.875 0 0 0 10 18 0.625 1.875 0 0 0 10 19 0.11.875 0 0 0 10 20 0.01 1.875 0 0 0 10 21 1.875 1.875 0 0 0 0 22 0.6251.875 0 0 0 0 23 0.1 1.875 0 0 0 0 24 0.01 1.875 0 0 0 0 25 1.875 1.8750 0 0 0 26 0.625 1.875 0 0 0 0 27 0.1 1.875 0 0 0 0 28 0.01 1.875 0 0 00 29 1.875 1.875 0 0 0 100 30 0.625 1.875 0 0 0 100 31 0.1 1.875 0 0 0100 32 0.01 1.875 0 0 0 100 33 1.875 1.875 0 0 0 0 34 0.625 1.875 0 0 00 35 0.1 1.875 0 0 0 0 36 0.01 1.875 0 0 0 0 37 1.875 1.875 0 0 0 0 380.625 1.875 0 0 0 0 39 0.1 1.875 0 0 0 0 40 0.01 1.875 0 0 0 0 41 0 1.5150 0 0 0 42 0 1.5 0 150 0 0 43 0 1.5 150 0 0.1 0 44 0 1.5 150 0 2.0 045 0 1.5 0 150 0.1 0 46 0 1.5 0 150 2.0 0 47 0 1.5 150 0 0 10 48 0 1.5 0150 0 10 49 0 1.5 150 0 0.1 0 50 0 1.5 150 0 2.0 0 51 0 1.5 0 150 0.1 052 0 1.5 0 150 2.0 0 53 0 1.5 150 0 0 100 54 0 1.5 0 150 0 100 55 0 1.5150 0 0.1 0 56 0 1.5 150 0 2.0 0 57 0 1.5 0 150 0.1 0 58 0 1.5 0 150 2.00 59 1.5 1.5 30 0 0 0 60 1.5 1.5 30 0 0 1 61 1.5 1.5 30 0 0 0 62 1.5 1.530 0 0 0 63 1.5 1.5 30 0 0 10 64 1.5 1.5 30 0 0 0 65 1.5 1.5 30 0 0 0 661.5 1.5 30 0 0 100 67 1.5 1.5 30 0 0 0 68 1.5 1.5 30 0 0 0 69 1.5 1.5 030 0 0 70 1.5 1.5 0 30 0 1 71 1.5 1.5 0 30 0 0 72 1.5 1.5 0 30 0 0 731.5 1.5 0 30 0 10 74 1.5 1.5 0 30 0 0 75 1.5 1.5 0 30 0 0 76 1.5 1.5 030 0 100 77 1.5 1.5 0 30 0 0 78 1.5 1.5 0 30 0 0 79 1.5 1.5 30 0 0.1 080 1.5 1.5 30 0 0.1 1 81 1.5 1.5 30 0 0.1 0 82 1.5 1.5 30 0 0.1 0 83 1.51.5 30 0 0.1 10 84 1.5 1.5 30 0 0.1 0 85 1.5 1.5 30 0 0.1 0 86 1.5 1.530 0 0.1 100 87 1.5 1.5 30 0 0.1 0 88 1.5 1.5 30 0 0.1 0 89 1.5 1.5 30 02 0 90 1.5 1.5 30 0 2 1 91 1.5 1.5 30 0 2 0 92 1.5 1.5 30 0 2 0 93 1.51.5 30 0 2 10 94 1.5 1.5 30 0 2 0 95 1.5 1.5 30 0 2 0 96 1.5 1.5 30 0 2100 97 1.5 1.5 30 0 2 0 98 1.5 1.5 30 0 2 0 99 1.5 1.5 0 30 0 0 100 1.51.5 0 30 0 1 101 1.5 1.5 0 30 0 0 102 1.5 1.5 0 30 0 0 103 1.5 1.5 0 300 10 104 1.5 1.5 0 30 0 0 105 1.5 1.5 0 30 0 0 106 1.5 1.5 0 30 0 100107 1.5 1.5 0 30 0 0 108 1.5 1.5 0 30 0 0 109 1.5 1.5 0 30 0.1 0 110 1.51.5 0 30 0.1 1 111 1.5 1.5 0 30 0.1 0 112 1.5 1.5 0 30 0.1 0 113 1.5 1.50 30 0.1 10 114 1.5 1.5 0 30 0.1 0 115 1.5 1.5 0 30 0.1 0 116 1.5 1.5 030 0.1 100 117 1.5 1.5 0 30 0.1 0 118 1.5 1.5 0 30 0.1 0 119 1.5 1.5 030 2 0 120 1.5 1.5 0 30 2 1 121 1.5 1.5 0 30 2 0 122 1.5 1.5 0 30 2 0123 1.5 1.5 0 30 2 10 124 1.5 1.5 0 30 2 0 125 1.5 1.5 0 30 2 0 126 1.51.5 0 30 2 100 127 1.5 1.5 0 30 2 0 128 1.5 1.5 0 30 2 0 129 0.5 1.5 300 0 0 130 0.5 1.5 30 0 0 1 131 0.5 1.5 30 0 0 0 132 0.5 1.5 30 0 0 0 1330.5 1.5 30 0 0 10 134 0.5 1.5 30 0 0 0 135 0.5 1.5 30 0 0 0 136 0.5 1.530 0 0 100 137 0.5 1.5 30 0 0 0 138 0.5 1.5 30 0 0 0 139 0.5 1.5 0 30 00 140 0.5 1.5 0 30 0 1 141 0.5 1.5 0 30 0 0 142 0.5 1.5 0 30 0 0 142 0.51.5 0 30 0 10 144 0.5 1.5 0 30 0 0 145 0.5 1.5 0 30 0 0 146 0.5 1.5 0 300 100 147 0.5 1.5 0 30 0 0 148 0.5 1.5 0 30 0 0 149 0.5 1.5 30 0 0.1 0150 0.5 1.5 30 0 0.1 1 151 0.5 1.5 30 0 0.1 0 152 0.5 1.5 30 0 0.1 0 1530.5 1.5 30 0 0.1 10 154 0.5 1.5 30 0 0.1 0 155 0.5 1.5 30 0 0.1 0 1560.5 1.5 30 0 0.1 100 157 0.5 1.5 30 0 0.1 0 158 0.5 1.5 30 0 0.1 0 1590.5 1.5 30 0 2 0 160 0.5 1.5 30 0 2 1 161 0.5 1.5 30 0 2 0 162 0.5 1.530 0 2 0 163 0.5 1.5 30 0 2 10 164 0.5 1.5 30 0 2 0 165 0.5 1.5 30 0 2 0166 0.5 1.5 30 0 2 100 167 0.5 1.5 30 0 2 0 168 0.5 1.5 30 0 2 0 169 0.51.5 0 30 0 0 170 0.5 1.5 0 30 0 1 171 0.5 1.5 0 30 0 0 172 0.5 1.5 0 300 0 173 0.5 1.5 0 30 0 10 174 0.5 1.5 0 30 0 0 175 0.5 1.5 0 30 0 0 1760.5 1.5 0 30 0 100 177 0.5 1.5 0 30 0 0 178 0.5 1.5 0 30 0 0 179 0.5 1.50 30 0.1 0 180 0.5 1.5 0 30 0.1 1 181 0.5 1.5 0 30 0.1 0 182 0.5 1.5 030 0.1 0 183 0.5 1.5 0 30 0.1 10 184 0.5 1.5 0 30 0.1 0 185 0.5 1.5 0 300.1 0 186 0.5 1.5 0 30 0.1 100 187 0.5 1.5 0 30 0.1 0 188 0.5 1.5 0 300.1 0 189 0.5 1.5 0 30 2 0 190 0.5 1.5 0 30 2 1 191 0.5 1.5 0 30 2 0 1920.5 1.5 0 30 2 0 193 0.5 1.5 0 30 2 10 194 0.5 1.5 0 30 2 0 195 0.5 1.50 30 2 0 196 0.5 1.5 0 30 2 100 197 0.5 1.5 0 30 2 0 198 0.5 1.5 0 30 20 199 4.0 1.5 30 0 0 0 200 4.0 1.5 30 0 0 1 201 4.0 1.5 30 0 0 0 202 4.01.5 30 0 0 0 203 4.0 1.5 30 0 0 10 204 4.0 1.5 30 0 0 0 205 4.0 1.5 30 00 0 206 4.0 1.5 30 0 0 100 207 4.0 1.5 30 0 0 0 208 4.0 1.5 30 0 0 0 2094.0 1.5 0 30 0 0 210 4.0 1.5 0 30 0 1 211 4.0 1.5 0 30 0 0 212 4.0 1.5 030 0 0 213 4.0 1.5 0 30 0 10 214 4.0 1.5 0 30 0 0 215 4.0 1.5 0 30 0 0216 4.0 1.5 0 30 0 100 217 4.0 1.5 0 30 0 0 218 4.0 1.5 0 30 0 0 219 4.01.5 30 0 0.1 0 220 4.0 1.5 30 0 0.1 1 221 4.0 1.5 30 0 0.1 0 222 4.0 1.530 0 0.1 0 223 4.0 1.5 30 0 0.1 10 224 4.0 1.5 30 0 0.1 0 225 4.0 1.5 300 0.1 0 226 4.0 1.5 30 0 0.1 100 227 4.0 1.5 30 0 0.1 0 228 4.0 1.5 30 00.1 0 229 4.0 1.5 30 0 2 0 230 4.0 1.5 30 0 2 1 231 4.0 1.5 30 0 2 0 2324.0 1.5 30 0 2 0 233 4.0 1.5 30 0 2 10 234 4.0 1.5 30 0 2 0 235 4.0 1.530 0 2 0 236 4.0 1.5 30 0 2 100 237 4.0 1.5 30 0 2 0 238 4.0 1.5 30 0 20 239 4.0 1.5 0 30 0 0 240 4.0 1.5 0 30 0 1 241 4.0 1.5 0 30 0 0 242 4.01.5 0 30 0 0 243 4.0 1.5 0 30 0 10 244 4.0 1.5 0 30 0 0 245 4.0 1.5 0 300 0 246 4.0 1.5 0 30 0 100 247 4.0 1.5 0 30 0 0 248 4.0 1.5 0 30 0 0 2494.0 1.5 0 30 0.1 0 250 4.0 1.5 0 30 0.1 1 251 4.0 1.5 0 30 0.1 0 252 4.01.5 0 30 0.1 0 253 4.0 1.5 0 30 0.1 10 254 4.0 1.5 0 30 0.1 0 255 4.01.5 0 30 0.1 0 256 4.0 1.5 0 30 0.1 100 257 4.0 1.5 0 30 0.1 0 258 4.01.5 0 30 0.1 0 259 4.0 1.5 0 30 2 0 260 4.0 1.5 0 30 2 1 261 4.0 1.5 030 2 0 262 4.0 1.5 0 30 2 0 263 4.0 1.5 0 30 2 10 264 4.0 1.5 0 30 2 0265 4.0 1.5 0 30 2 0 266 4.0 1.5 0 30 2 100 267 4.0 1.5 0 30 2 0 268 4.01.5 0 30 2 0 269 1.0 0 150 0.0 0.0 0.0 270 11.0 0 150 0.0 0.0 0.0 2712.0 0 150 0.0 0.0 0.0 272 0.1 0 25 0.0 0.0 0.0 273 0.1 0 200 0.0 0.0 0.0274 11.0 0 25 0.0 0.0 0.0 275 11.0 0 200 0.0 0.0 0.0 276 0.1 0 25 0.02.0 0.0 277 0.1 0 25 0.0 0.1 0.0 278 11.0 0 200 0.0 2.0 0.0 279 11.0 0200 0.0 0.1 0.0 280 0.1 0 0.0 25 0.0 0.0 281 0.1 0 0.0 200 0.0 0.0 28211.0 0 0.0 25 0.0 0.0 283 11.0 0 0.0 200 0.0 0.0 284 0.1 0 0.0 25 2.00.0 285 0.1 0 0.0 25 0.1 0.0 286 11.0 0 0.0 200 2.0 0.0 287 11.0 0 0.0200 0.1 0.0 288 0.1 0 25 0.0 0.0 0.1 289 0.1 0 200 0.0 0.0 0.1 290 11.00 25 0.0 0.0 0.1 291 11.0 0 200 0.0 0.0 0.1 292 0.1 0 25 0.0 2.0 0.1 2930.1 0 25 0.0 0.1 0.1 294 11.0 0 200 0.0 2.0 0.1 295 11.0 0 200 0.0 0.10.1 296 0.1 0 0.0 25 0.0 0.1 297 0.1 0 0.0 200 0.0 0.1 298 11.0 0 0.0 250.0 0.1 299 11.0 0 0.0 200 0.0 0.1 300 0.1 0 0.0 25 2.0 0.1 301 0.1 00.0 25 0.1 0.1 302 11.0 0 0.0 200 2.0 0.1 303 11.0 0 0.0 200 0.1 0.1 3040.1 0 25 0.0 0.0 200 305 0.1 0 200 0.0 0.0 200 306 11.0 0 25 0.0 0.0 200307 11.0 0 200 0.0 0.0 200 308 0.1 0 25 0.0 2.0 200 309 0.1 0 25 0.0 0.1200 310 11.0 0 200 0.0 2.0 200 311 11.0 0 200 0.0 0.1 200 312 0.1 0 0.025 0.0 200 313 0.1 0 0.0 200 0.0 200 314 11.0 0 0.0 25 0.0 200 315 11.00 0.0 200 0.0 200 316 0.1 0 0.0 25 2.0 200 317 0.1 0 0.0 25 0.1 200 31811.0 0 0.0 200 2.0 200 319 11.0 0 0.0 200 0.1 200 320 0.1 0 25 0.0 0.00.0 321 0.1 0 200 0.0 0.0 0.0 322 11.0 0 25 0.0 0.0 0.0 323 11.0 0 2000.0 0.0 0.0 324 0.1 0 25 0.0 2.0 0.0 325 0.1 0 25 0.0 0.1 0.0 326 11.0 0200 0.0 2.0 0.0 327 11.0 0 200 0.0 0.1 0.0 328 0.1 0 0.0 25 0.0 0.0 3290.1 0 0.0 200 0.0 0.0 330 11.0 0 0.0 25 0.0 0.0 331 11.0 0 0.0 200 0.00.0 332 0.1 0 0.0 25 2.0 0.0 333 0.1 0 0.0 25 0.1 0.0 334 11.0 0 0.0 2002.0 0.0 335 11.0 0 0.0 200 0.1 0.0 336 0.1 0 25 0.0 0.0 0.0 337 0.1 0200 0.0 0.0 0.0 338 11.0 0 25 0.0 0.0 0.0 339 11.0 0 200 0.0 0.0 0.0 3400.1 0 25 0.0 2.0 0.0 341 0.1 0 25 0.0 0.1 0.0 342 11.0 0 200 0.0 52.00.0 343 11.0 0 200 0.0 0.1 0.0 344 0.1 0 0.0 25 0.0 0.0 345 0.1 0 0.0200 0.0 0.0 346 11.0 0 0.0 25 0.0 0.0 347 11.0 0 0.0 200 0.0 0.0 348 0.10 0.0 25 2.0 0.0 349 0.1 0 0.0 25 0.1 0.0 350 11.0 0 0.0 200 2.0 0.0 35111.0 0 0.0 200 0.1 0.0 352 0.1 0 25 0.0 0.0 0.0 353 0.1 0 200 0.0 0.00.0 354 11.0 0 25 0.0 0.0 0.0 355 11.0 0 200 0.0 0.0 0.0 356 0.1 0 250.0 2.0 0.0 357 0.1 0 25 0.0 0.1 0.0 358 11.0 0 200 0.0 2.0 0.0 359 11.00 200 0.0 0.1 0.0 360 0.1 0 0.0 25 0.0 0.0 361 0.1 0 0.0 200 0.0 0.0 36211.0 0 0.0 25 0.0 0.0 363 11.0 0 0.0 200 0.0 0.0 364 0.1 0 0.0 25 2.00.0 365 0.1 0 0.0 25 0.1 0.0 366 11.0 0 0.0 200 2.0 0.0 367 11.0 0 0.0200 0.1 0.0 368 0.1 0 25 0.0 0.0 0.0 369 0.1 0 200 0.0 0.0 0.0 370 11.00 25 0.0 0.0 0.0 371 11.0 0 200 0.0 0.0 0.0 372 0.1 0 25 0.0 2.0 0.0 3730.1 0 25 0.0 0.1 0.0 374 11.0 0 200 0.0 2.0 0.0 375 11.0 0 200 0.0 0.10.0 376 0.1 0 0 25 2.0 0.0 377 0.1 0 0 25 0.1 0.0 378 11.0 0 0 200 2.00.0 379 11.0 0 0 200 0.1 0.0 380 1.5 2.0 0 0 0 0 381 1.5^(b) 2.0 0 0 0 0Osmolality Formulation Glycine Buffer (mM Tris Buffer (mM) Water(mOsmo/kg; +/−200) pH (+/−3.0)  1 0 0 q.s. 300 5.0  2 0 0 q.s. 300 5.0 3 0 0 q.s. 300 5.0  4 0 0 q.s. 300 5.0  5 0 0 q.s. 300 5.0  6 0 0 q.s.300 5.0  7 0 0 q.s. 300 5.0  8 0 0 q.s. 300 5.0  9 1 0 q.s. 300 5.0  101 0 q.s. 300 5.0  11 1 0 q.s. 300 5.0  12 1 0 q.s. 300 5.0  13 0 1 q.s.300 5.0  14 0 1 q.s. 300 5.0  15 0 1 q.s. 300 5.0  16 0 1 q.s. 300 5.0 17 0 0 q.s. 300 5.0  18 0 0 q.s. 300 5.0  19 0 0 q.s. 300 5.0  20 0 0q.s. 300 5.0  21 10 0 q.s. 300 5.0  22 10 0 q.s. 300 5.0  23 10 0 q.s.300 5.0  24 10 0 q.s. 300 5.0  25 0 10 q.s. 300 5.0  26 0 10 q.s. 3005.0  27 0 10 q.s. 300 5.0  28 0 10 q.s. 300 5.0  29 0 0 q.s. 300 5.0  300 0 q.s. 300 5.0  31 0 0 q.s. 300 5.0  32 0 0 q.s. 300 5.0  33 100 0q.s. 300 5.0  34 100 0 q.s. 300 5.0  35 100 0 q.s. 300 5.0  36 100 0q.s. 300 5.0  37 0 100 q.s. 300 5.0  38 0 100 q.s. 300 5.0  39 0 100q.s. 300 5.0  40 0 100 q.s. 300 5.0  41 0 0 q.s. 300 5.0  42 0 0 q.s.300 5.0  43 0 0 q.s. 300 5.0  44 0 0 q.s. 300 5.0  45 0 0 q.s. 300 5.0 46 0 0 q.s. 300 5.0  47 0 0 q.s. 300 5.0  48 0 0 q.s. 300 5.0  49 10 0q.s. 300 5.0  50 10 0 q.s. 300 5.0  51 0 10 q.s. 300 5.0  52 0 10 q.s.300 5.0  53 0 0 q.s. 300 5.0  54 0 0 q.s. 300 5.0  55 100 0 q.s. 300 5.0 56 100 0 q.s. 300 5.0  57 0 100 q.s. 300 5.0  58 0 100 q.s. 300 5.0  590 0 q.s. 300 5.0  60 0 0 q.s. 300 5.0  61 1 0 q.s. 300 5.0  62 0 1 q.s.300 5.0  63 0 0 q.s. 300 5.0  64 10 0 q.s. 300 5.0  65 0 10 q.s. 300 5.0 66 0 0 q.s. 300 5.0  67 100 0 q.s. 300 5.0  68 0 100 q.s. 300 5.0  69 00 q.s. 300 5.0  70 0 0 q.s. 300 5.0  71 1 0 q.s. 300 5.0  72 0 1 q.s.300 5.0  73 0 0 q.s. 300 5.0  74 10 0 q.s. 300 5.0  75 0 10 q.s. 300 5.0 76 0 0 q.s. 300 5.0  77 100 0 q.s. 300 5.0  78 0 100 q.s. 300 5.0  79 00 q.s. 300 5.0  80 0 0 q.s. 300 5.0  81 1 0 q.s. 300 5.0  82 0 1 q.s.300 5.0  83 0 0 q.s. 300 5.0  84 10 0 q.s. 300 5.0  85 0 10 q.s. 300 5.0 86 0 0 q.s. 300 5.0  87 100 0 q.s. 300 5.0  88 0 100 q.s. 300 5.0  89 00 q.s. 300 5.0  90 0 0 q.s. 300 5.0  91 1 0 q.s. 300 5.0  92 0 1 q.s.300 5.0  93 0 0 q.s. 300 5.0  94 10 0 q.s. 300 5.0  95 0 10 q.s. 300 5.0 96 0 0 q.s. 300 5.0  97 100 0 q.s. 300 5.0  98 0 100 q.s. 300 5.0  99 00 q.s. 300 5.0 100 0 0 q.s. 300 5.0 101 1 0 q.s. 300 5.0 102 0 1 q.s.300 5.0 103 0 0 q.s. 300 5.0 104 10 0 q.s. 300 5.0 105 0 10 q.s. 300 5.0106 0 0 q.s. 300 5.0 107 100 0 q.s. 300 5.0 108 0 100 q.s. 300 5.0 109 00 q.s. 300 5.0 110 0 0 q.s. 300 5.0 111 1 0 q.s. 300 5.0 112 0 1 q.s.300 5.0 113 0 0 q.s. 300 5.0 114 10 0 q.s. 300 5.0 115 0 10 q.s. 300 5.0116 0 0 q.s. 300 5.0 117 100 0 q.s. 300 5.0 118 0 100 q.s. 300 5.0 119 00 q.s. 300 5.0 120 0 0 q.s. 300 5.0 121 1 0 q.s. 300 5.0 122 0 1 q.s.300 5.0 123 0 0 q.s. 300 5.0 124 10 0 q.s. 300 5.0 125 0 10 q.s. 300 5.0126 0 0 q.s. 300 5.0 127 100 0 q.s. 300 5.0 128 0 100 q.s. 300 5.0 129 00 q.s. 300 5.0 130 0 0 q.s. 300 5.0 131 1 0 q.s. 300 5.0 132 0 1 q.s.300 5.0 133 0 0 q.s. 300 5.0 134 10 0 q.s. 300 5.0 135 0 10 q.s. 300 5.0136 0 0 q.s. 300 5.0 137 100 0 q.s. 300 5.0 138 0 100 q.s. 300 5.0 139 00 q.s. 300 5.0 140 0 0 q.s. 300 5.0 141 1 0 q.s. 300 5.0 142 0 1 q.s.300 5.0 142 0 0 q.s. 300 5.0 144 10 0 q.s. 300 5.0 145 0 10 q.s. 300 5.0146 0 0 q.s. 300 5.0 147 100 0 q.s. 300 5.0 148 0 100 q.s. 300 5.0 149 00 q.s. 300 5.0 150 0 0 q.s. 300 5.0 151 1 0 q.s. 300 5.0 152 0 1 q.s.300 5.0 153 0 0 q.s. 300 5.0 154 10 0 q.s. 300 5.0 155 0 10 q.s. 300 5.0156 0 0 q.s. 300 5.0 157 100 0 q.s. 300 5.0 158 0 100 q.s. 300 5.0 159 00 q.s. 300 5.0 160 0 0 q.s. 300 5.0 161 1 0 q.s. 300 5.0 162 0 1 q.s.300 5.0 163 0 0 q.s. 300 5.0 164 10 0 q.s. 300 5.0 165 0 10 q.s. 300 5.0166 0 0 q.s. 300 5.0 167 100 0 q.s. 300 5.0 168 0 100 q.s. 300 5.0 169 00 q.s. 300 5.0 170 0 0 q.s. 300 5.0 171 1 0 q.s. 300 5.0 172 0 1 q.s.300 5.0 173 0 0 q.s. 300 5.0 174 10 0 q.s. 300 5.0 175 0 10 q.s. 300 5.0176 0 0 q.s. 300 5.0 177 100 0 q.s. 300 5.0 178 0 100 q.s. 300 5.0 179 00 q.s. 300 5.0 180 0 0 q.s. 300 5.0 181 1 0 q.s. 300 5.0 182 0 1 q.s.300 5.0 183 0 0 q.s. 300 5.0 184 10 0 q.s. 300 5.0 185 0 10 q.s. 300 5.0186 0 0 q.s. 300 5.0 187 100 0 q.s. 300 5.0 188 0 100 q.s. 300 5.0 189 00 q.s. 300 5.0 190 0 0 q.s. 300 5.0 191 1 0 q.s. 300 5.0 192 0 1 q.s.300 5.0 193 0 0 q.s. 300 5.0 194 10 0 q.s. 300 5.0 195 0 10 q.s. 300 5.0196 0 0 q.s. 300 5.0 197 100 0 q.s. 300 5.0 198 0 100 q.s. 300 5.0 199 00 q.s. 300 5.0 200 0 0 q.s. 300 5.0 201 1 0 q.s. 300 5.0 202 0 1 q.s.300 5.0 203 0 0 q.s. 300 5.0 204 10 0 q.s. 300 5.0 205 0 10 q.s. 300 5.0206 0 0 q.s. 300 5.0 207 100 0 q.s. 300 5.0 208 0 100 q.s. 300 5.0 209 00 q.s. 300 5.0 210 0 0 q.s. 300 5.0 211 1 0 q.s. 300 5.0 212 0 1 q.s.300 5.0 213 0 0 q.s. 300 5.0 214 10 0 q.s. 300 5.0 215 0 10 q.s. 300 5.0216 0 0 q.s. 300 5.0 217 100 0 q.s. 300 5.0 218 0 100 q.s. 300 5.0 219 00 q.s. 300 5.0 220 0 0 q.s. 300 5.0 221 1 0 q.s. 300 5.0 222 0 1 q.s.300 5.0 223 0 0 q.s. 300 5.0 224 10 0 q.s. 300 5.0 225 0 10 q.s. 300 5.0226 0 0 q.s. 300 5.0 227 100 0 q.s. 300 5.0 228 0 100 q.s. 300 5.0 229 00 q.s. 300 5.0 230 0 0 q.s. 300 5.0 231 1 0 q.s. 300 5.0 232 0 1 q.s.300 5.0 233 0 0 q.s. 300 5.0 234 10 0 q.s. 300 5.0 235 0 10 q.s. 300 5.0236 0 0 q.s. 300 5.0 237 100 0 q.s. 300 5.0 238 0 100 q.s. 300 5.0 239 00 q.s. 300 5.0 240 0 0 q.s. 300 5.0 241 1 0 q.s. 300 5.0 242 0 1 q.s.300 5.0 243 0 0 q.s. 300 5.0 244 10 0 q.s. 300 5.0 245 0 10 q.s. 300 5.0246 0 0 q.s. 300 5.0 247 100 0 q.s. 300 5.0 248 0 100 q.s. 300 5.0 249 00 q.s. 300 5.0 250 0 0 q.s. 300 5.0 251 1 0 q.s. 300 5.0 252 0 1 q.s.300 5.0 253 0 0 q.s. 300 5.0 254 10 0 q.s. 300 5.0 255 0 10 q.s. 300 5.0256 0 0 q.s. 300 5.0 257 100 0 q.s. 300 5.0 258 0 100 q.s. 300 5.0 259 00 q.s. 300 5.0 260 0 0 q.s. 300 5.0 261 1 0 q.s. 300 5.0 262 0 1 q.s.300 5.0 263 0 0 q.s. 300 5.0 264 10 0 q.s. 300 5.0 265 0 10 q.s. 300 5.0266 0 0 q.s. 300 5.0 267 100 0 q.s. 300 5.0 268 0 100 q.s. 300 5.0 2690.0 0.0 q.s. 300 5.0 270 0.0 0.0 q.s. 300 5.0 271 0.0 0.0 q.s. 300 5.0272 0.0 0.0 q.s. 300 5.0 273 0.0 0.0 q.s. 300 5.0 274 0.0 0.0 q.s. 3005.0 275 0.0 0.0 q.s. 300 5.0 276 0.0 0.0 q.s. 300 5.0 277 0.0 0.0 q.s.300 5.0 278 0.0 0.0 q.s. 300 5.0 279 0.0 0.0 q.s. 300 5.0 280 0.0 0.0q.s. 300 5.0 281 0.0 0.0 q.s. 300 5.0 282 0.0 0.0 q.s. 300 5.0 283 0.00.0 q.s. 300 5.0 284 0.0 0.0 q.s. 300 5.0 285 0.0 0.0 q.s. 300 5.0 2860.0 0.0 q.s. 300 5.0 287 0.0 0.0 q.s. 300 5.0 288 0.0 0.0 q.s. 300 5.0289 0.0 0.0 q.s. 300 5.0 290 0.0 0.0 q.s. 300 5.0 291 0.0 0.0 q.s. 3005.0 292 0.0 0.0 q.s. 300 5.0 293 0.0 0.0 q.s. 300 5.0 294 0.0 0.0 q.s.300 5.0 295 0.0 0.0 q.s. 300 5.0 296 0.0 0.0 q.s. 300 5.0 297 0.0 0.0q.s. 300 5.0 298 0.0 0.0 q.s. 300 5.0 299 0.0 0.0 q.s. 300 5.0 300 0.00.0 q.s. 300 5.0 301 0.0 0.0 q.s. 300 5.0 302 0.0 0.0 q.s. 300 5.0 3030.0 0.0 q.s. 300 5.0 304 0.0 0.0 q.s. 300 5.0 305 0.0 0.0 q.s. 500 5.0306 0.0 0.0 q.s. 300 5.0 307 0.0 0.0 q.s. 500 5.0 308 0.0 0.0 q.s. 3005.0 309 0.0 0.0 q.s. 300 5.0 310 0.0 0.0 q.s. 500 5.0 311 0.0 0.0 q.s.500 5.0 312 0.0 0.0 q.s. 300 5.0 313 0.0 0.0 q.s. 500 5.0 314 0.0 0.0q.s. 300 5.0 315 0.0 0.0 q.s. 500 5.0 316 0.0 0.0 q.s. 300 5.0 317 0.00.0 q.s. 300 5.0 318 0.0 0.0 q.s. 500 5.0 319 0.0 0.0 q.s. 500 5.0 3200.1 0.0 q.s. 300 6.5 321 0.1 0.0 q.s. 300 6.5 322 0.1 0.0 q.s. 300 6.5323 0.1 0.0 q.s. 300 6.5 324 0.1 0.0 q.s. 300 6.5 325 0.1 0.0 q.s. 3006.5 326 0.1 0.0 q.s. 300 6.5 327 0.1 0.0 q.s. 300 6.5 328 0.1 0.0 q.s.300 6.5 329 0.1 0.0 q.s. 300 6.5 330 0.1 0.0 q.s. 300 6.5 331 0.1 0.0q.s. 300 6.5 332 0.1 0.0 q.s. 300 6.5 333 0.1 0.0 q.s. 300 6.5 334 0.10.0 q.s. 300 6.5 335 0.1 0.0 q.s. 300 6.5 336 200 0.0 q.s. 300 6.5 337200 0.0 q.s. 500 6.5 338 200 0.0 q.s. 300 6.5 339 200 0.0 q.s. 500 6.5340 200 0.0 q.s. 300 6.5 341 200 0.0 q.s. 300 6.5 342 200 0.0 q.s. 5006.5 343 200 0.0 q.s. 500 6.5 344 200 0.0 q.s. 300 6.5 345 200 0.0 q.s.500 6.5 346 200 0.0 q.s. 300 6.5 347 200 0.0 q.s. 500 6.5 348 200 0.0q.s. 300 6.5 349 200 0.0 q.s. 300 6.5 350 200 0.0 q.s. 500 6.5 351 2000.0 q.s. 500 6.5 352 0.0 0.1 q.s. 300 5.0 353 0.0 0.1 q.s. 300 5.0 3540.0 0.1 q.s. 300 5.0 355 0.0 0.1 q.s. 300 5.0 356 0.0 0.1 q.s. 300 5.0357 0.0 0.1 q.s. 300 5.0 358 0.0 0.1 q.s. 300 5.0 359 0.0 0.1 q.s. 3005.0 360 0.0 0.1 q.s. 300 5.0 361 0.0 0.1 q.s. 300 5.0 362 0.0 0.1 q.s.300 5.0 363 0.0 0.1 q.s. 300 5.0 364 0.0 0.1 q.s. 300 5.0 365 0.0 0.1q.s. 300 5.0 366 0.0 0.1 q.s. 300 5.0 367 0.0 0.1 q.s. 300 5.0 368 0.0200 q.s. 300 5.0 369 0.0 200 q.s. 500 5.0 370 0.0 200 q.s. 300 5.0 3710.0 200 q.s. 500 5.0 372 0.0 200 q.s. 300 5.0 373 0.0 200 q.s. 300 5.0374 0.0 200 q.s. 500 5.0 375 0.0 200 q.s. 500 5.0 376 0.0 200 q.s. 3005.0 377 0.0 200 q.s. 300 5.0 378 0.0 200 q.s. 500 5.0 379 0.0 200 q.s.500 5.0 380 0 0 q.s. 300 5.0 381 0 0 q.s. 300 5.0 ^(a)Nintedanib salt isany salt form described herein. Values in milligram/milliliternintedanib ^(b)Also contains 12.5 mg/mL pirfenidone

Example 5. Nintedanib Liquid Formulations

The objective of these studies was to determine the feasibility offormulating a standalone nintedanib esylate formulation and a fixed dosenintedanib esylate/pirfenidone combination formulation for nebulizationwith the following requirements:

-   -   Adequate long-term stability and shelf life (≥2 years at room        temperature    -   Suitable for oral inhalation:        -   Acceptable taste Comprised of at least 30 mM of permeant ion            (chloride or bromide ions)        -   Formulated to an osmolality in the range of 50 mOsm/kg-600            mOsm/kg        -   pH 3-7.0

Formulation screening of stand alone nintedanib esylate and incombination with pirfenidone were conducted. Commonly used ionicosmolality adjusting agents include sodium chloride, sodium citrate,magnesium chloride were evaluated as excipients. In addition, mannitoland propylene glycol, which are ionic osmolality adjusting agents, werealso tested.

Nintedanib esylate was dissolved in water to either 1.5 mg/mL or 3.0mg/mL concentration, to which other excipients were added. The resultingsolutions, if not immediately precipitated, were filled into clear TypeI glass vials and sealed with a Teflon lined rubber stopper and aluminumcrimp cap. The test solutions were stored at ambient room condition inthe dark. Visual appearance was periodically assessed within 24 hoursand periodically thereafter. Table 31 summarizes the initial formulationscreening results.

TABLE 31 Compatibility Assessment of Nintedanib Esylate with Pirfenidoneand Various Osmolality Adjusting Agents Nonionic osmol Nintedanib Sodiumadjusting Osmolality Solution Esylate Pirfenidone NaCl Citrate MgCl₂agent % (mOsm/ ID (mg/mL) (mg/mL) (mM) (mM) (mM) w/w kg) pH Observation101-01- 1.5 0 60 0 0 0 120 NT Light precip 10-01 after dissolution101-01- 1.5 12.5 60 0 0 0 182 NT Precip after 10-02 dissolution 101-01-1.5 0 30 0 0 1 125 4.75 Viscous, 11-03 (mannitol) precip w/in24 hrs101-01- 3.0 0 30 0 0 1 127 4.58 Viscous, 11-04 (mannitol) precip w/in 24hrs 101-01- 3.0 12.5 30 0 0 1 186 4.56 NO precip 12-01 (mannitol) thru 4months RT^(b) 101-01- 3.0 12.5 0 4.5 0 0 NT^(a) NT Precip upon 07-03NaCit addition 101-01- 3.0 12.5 30 0 0 0 125 4.51 Precip 08-03 w/in24hrs 101-01- 3.0 12.5 60 N/A N/A N/A NT NT Precip upon 08-04 additionNaCl 101-01- 3.0 N/A N/A N/A 50 N/A 144 NT Viscous, 12-02 precip w/in 24hrs 101-01- 3.0 N/A N/A N/A 100 N/A 271 4.75 Viscous, 12-03 precip w/in24 hrs 101-01- 3.0 12.5 N/A N/A 50 N/A NT NT Precip upon 13-01 additionMgCl₂ 101-01- 1.5 12.5 N/A N/A 25 N/A 133 NT Viscous, 13-02 precip w/in24 hrs 101-01- 1.5 12.5 N/A N/A 37.5 N/A 166 4.90 Viscous, 13-03 precipw/in 24 hrs 101-01- 1.5 12.5 N/A N/A 50 N/A 200 NT Viscous, 13-04 precipw/in 24 hrs 101-01- 1.5 N/A 30 N/A 50 1.5 268 4.87 Viscous, 13-05(propylene precip w/in glycol) 24 hrs 101-01- 1.5 12.5 30 N/A N/A 1.5328 4.93 NO precip 14-01 (propylene thru 4 glycol) months RT NT: nottested; ^(b)RT: Room temperature

Key findings from formulation screening study: Nintedanib esylate isincompatible with sodium citrate because nintedanib esylate precipitatedimmediately after the addition of sodium citrate (Formulation101-01-07-03). Nintedanib esylate is incompatible with sodium chlorideat 60 mM or higher as nintedanib esylate precipitated shortly afteradding sodium chloride (Formulations 10-01, 10-02 and 08-04). Nintedanibesylate may be compatible with sodium chloride at 30 mM as twoformulations containing NaCl at this concentration did not precipitate(even after 4 months) and those precipitated did not occur immediatelyafter the addition of NaCl. Formulations 101-01-12-01 and 101-01-14-01,both of which are nintedanib esylate/pirfenidone combinationformulations that contain a nonionic excipient, remained clear yellowsolution did not precipitate (remained in solution for at least 4months).

Out of the 16 formulations screened, only two formulations both of whichcontain nintedanib esylate and pirfenidone are physically stable. At thetime this study was carried out, it was not initially clear why: (1) thestandalone nintedanib esylate formulation (101-01-11-04 and101-01-13-05) precipitated while the combination nintedanibesylate/pirfenidone formulation 101-01-12-01 and 101-01-14-01 (whichhave similar composition as the respective standalone nintedanib esylateformulations) remained stable, and (2) why not all nintedanibesylate/pirfenidone combination formulations are stable (e.g.101-01-08-03).

Therefore, a three-tier drug-excipient compatibility study was conductedto gain insights into the compatibility of nintedanib esylate withvarious excipients: Tier 1: compatibility of nintedanib esylate with oneexcipient (nintedanib esylate+excipient). Tier 2: compatibility ofnintedanib esylate and pirfenidone with one excipient (nintedanibesylate+pirfenidone+excipient). Tier 3: compatibility of standalonenintedanib esylate or in combination with pirfenidone in 30 mM NaCl withone other osmolality adjusting agent (nintedanib esylate+30 mMNaCl+excipient or nintedanib esylate+pirfenidone+30 mM NaCl+excipient)

Tier 1: Nintedanib Esylate-Excipient Compatibility Study. Except wherenoted, all test solutions were formulated with 1.5 mg/mL nintedanibesylate. The concentrations of excipients are shown in Table 32. Testsolution 101-01-16-00 was filtered through a 0.22 micron PVDF filter,all other formulations were not filtered. The test solutions were filledinto 10 mL clear Type I glass vials and sealed with Teflon-lined rubberstopper and aluminum crimp cap.

TABLE 32 Compatibility of Nintedanib Esylate with NaCl, MgCl₂, mannitol,Propylene Glycol, Ethanol, sodium citrate and pirfenidone SolutionSolution Composition ID Initial Appearance Stability Nintedanib esylate101-01- Clear yellow solution Precipitated w/in 2 hours, Control 15-00precipitation initiated on the (control) wall of glass vial Filterednintenanib 101-01- Precip formed after Precipitated immediately afteresylate Control 16-00 filtration filtration (via 0.22 μm pvdf filter)Nintedanib esylate + 101-01- Clear yellow viscous Precipitated overnight30 mM NaCl 15-01 Nintedanib esylate + 101-01- Clear yellow viscousPrecipitated overnight 45 mM NaCl 15-02 Nintedanib esylate + 101-01-Clear yellow viscous Precipitated overnight 25 mM MgCl₂ 15-03 Nintedanibesylate + 101-01- Clear yellow solution No precipitation thru 4 months1% Mannitol 15-04 Nintedanib esylate + 101-01- Clear yellow solutionLight precip overnight 1.5% propylene 15-05 glycol Nintedanib esylate +101-01- Clear yellow solution Light precip overnight 1% EtOH 15-06Nintedanib esylate + 101-01- Precipitation formed Heavy precipitationformed 4.5 mM sodium 15-07 immediately immediately citrate Nintedanibesylate + 101-01- Clear yellow solution No precipitation thru 4 months12.5 mg/mL 15-08 pirfenidone 3 mg/mL 101-01- Clear yellow solution Noprecipitation thru 4 months nintedanib esylate + 15-09 12.5 mg/mLpirfenidone

Key findings: Nintedanib esylate control solution 101-01-05-01precipitated in clear borosilicate glass vials. Precipitation was firstobserved on the wall of the glass vial, indicating nintedanib esylate isnot compatible with clear borosilicate glass vial. Nintedanib esylatecontrol solution 101-01-05-01 filtered through 0.22 μm pvdf filterprecipitated immediately filtration, forming a milky yellowish greensuspension. This shows that nintedanib esylate is not compatible withPVDF membrane filter. Nintedanib esylate solutions containingpirfenidone (101-01-15-08 and -09) remains in solution form through 4months at room temperature, reconfirming pirfenidone has a stabilizingeffect on nintedanib esylate. Mannitol and to some extent, propyleneglycol and ethanol also have a stabilizing effect on nintedanib esylate.

Tier 2: Nintedanib-Pirfenidone-Excipient Compatibility Study. Exceptwhere noted, all formulations were formulated with 1.5 mg/mL nintedanibesylate and 12.5 mg/mL pirfenidone. The concentrations of the excipientsused are shown in Table 33. Except formulation 101-01-16-02 where it wasfiltered through a 0.22 micron PVDF filter, all other formulations werenot filtered. All formulations were stored in a 10 mL clear Type I glassvial sealed with Teflon-lined rubber stopper and aluminum crimp cap.

TABLE 33 Compatibility of nintedanib esylate, pirfenidone and anexcipient in a three- component solution Formulation Formulation IDComposition Appearance Stability 101-01-16- Nintedanib esylate + Clearyellow No precipitation thru 4 months 01 pirfenidone control solution101-01-16- Filtered Nintedanib Light precip Precipitated within 2 hoursafter 02 esylate + pirfenidone observed within 2 preparation control(via 0.22 μm hours pvdf filter) 101-01-16- Nintedanib esylate + Clearyellow Crystals observed on glass vial 03 pirfenidone control + 30 mMsolution wall after 1 month NaCl 101-01-16- Nintedanib esylate + Clearyellow Precipitated within 2 days 04 pirfenidone control + 45 mMsolution NaCl 101-01-16- Nintedanib esylate + Clear yellow Crystalsobserved on glass wall 05 pirfenidone control + 25 mM solution after onemonth MgCl₂ 101-01-16- Nintedanib esylate + Clear yellow Noprecipitation thru 4 months 06 pirfenidone control + solution 1%mannitol 101-01-16- Nintedanib esylate + Clear yellow No precipitationthru 4 months 07 pirfenidone control + solution 1.5% propylene glycol101-01-16- Nintedanib esylate + Clear yellow No precipitation thru 4months 08 pirfenidone control + solution 1% ethanol

Key findings: The nintedanib esylate plus pirfenidone control solution101-01-16-01 is free of precipitates through 4 months, confirming thatpirfenidone has a stabilizing effect on nintedanib esylate in solution.Nintedanib esylate is incompatible with PVDF filter (101-01-16-02), evenin the presence of pirfenidone, confirming observation made in Tier 1testing. Mannitol, propylene glycol and ethanol do not adversely effectnintedanib stability (101-01-16-06 through -08)

Tier 3: Compatibility of nintedanib esylate and nintedanib esylate pluspirfenidone control with sodium chloride and a second excipient wasassessed. Specifically, the compatibility of nintedanib esylate andnintedanib esylate plus pirfenidone with sodium chloride at 30 mM andwith another excipient was evaluated at the minimum concentration of 30mM (to provide adequate permeant ion concentration to the airway toattain acceptable tolerability). A second excipient (mannitol, propyleneglycol, ethanol) was used to adjust the osmolality to an acceptablerange (200-400 mOsm/kg). nintedanib esylate was tested 1.5 mg/mL, andpirfenidone, where applicable, was at 12.5 mg/mL. The test solutionswere filled into 10 mL clear Type I glass vials with Teflon lined rubberstopper and aluminum crimp caps and stored at ambient room conditionaway from light. Results are shown in Table 34.

TABLE 34 Combability of nintedanib esylate (1.5 mg/mL) and nintedanibesylate (1.5 mg/mL) plus pirfenidone (12.5 mg/mL) in 30 mM NaCl with asecond excipient Initial Composition Form ID Appearance StabilityNintedanib esylate + 30 mM 101-01- Clear yellow Precipitation within 24hours NaCl + 1% 17-02 viscous mannitol Nintedanib esylate + 30 mM101-01- Clear yellow Precipitation within 24 hours NaCl + 1.5% 17-03viscous propylene glycol Nintedanib esylate + 30 mM 101-01- Clear yellowPrecipitation within 24 hours NaCl + 1% 17-04 viscous ethanol Nintedanibesylate + 101-01- Clear yellow Crystals observed on wall of glasspirfenidone + 30 mM 17-06 solution vial after one month NaCl + 1%mannitol Nintedanib esylate + 101-01- Clear yellow No precipitation thru4 months pirfenidone + 30 mM 17-07 solution NaCl + 1.5% propylene glycolNintedanib esylate + 101-01- Clear yellow No precipitation thru 4 monthspirfenidone + 30 mM 17-08 solution NaCl + 1% ethanol

Key findings: Nintedanib esylate by itself is not stable in 30 mM NaCl(101-01-17-02 through -06). Pirfenidone, in combination with eitherpropylene glycol or ethanol, pirfenidone, can stabilize nintedanibesylate formulated in 30 mM sodium chloride solution (101-01-17-07 and-08).

Compatibility of Nintedanib Esylate with Container System and Type ofMembrane Filter: The objective of this study is to determine thesuitability of low density polyethylene (LDPE) vials and nylon filtersfor use with nintedanib esylate standalone and nintedanib esylate pluspirfenidone combination formulations. The compositions of the testsolutions, filtration process and type of container used are listed inTable 35. The test samples were stored at ambient room condition andperiodically check for precipitation or crystallization.

TABLE 35 Compatibility assessment of nintedanib esylate solutions withnylon filter and LDPE vials Composition Form ID Container TypeFiltration Stability Nintedanib 101-01- Clear glass vial Not filteredPrecipitated after 5 minutes esylate 0.5 mg/mL 23-03 101-01- Clear glassvial Nylon Precipitated after 5 minutes 23-04 filtered 101-01- LDPE vialNot filtered No precipitation through 4 24-01 months 101-01- Amber TypeI Not filtered No precipitation through 4 24-02 glass vial monthsNintedanib 101-01- LDPE vial Not filtered No precipitation through 4esylate 1.5 mg/mL 24-05 months 101-01- LDPE vial Nylon filter Noprecipitation through 4 24-06 months Nintedanib 101-01- LDPE vial Notfiltered No precipitation through 4 esylate 1.5 mg/mL + 27-02 months1.5% 101-01- LDPE vial Nylon filter No precipitation through 4 propylene27-03 months glycol Nintedanib 101-01- Clear glass vial Not filteredPrecipitated overnight esylate + 30 mM 21-01 NaCl 101-01- LDPE vial Notfiltered Precipitated overnight 21-02 101-01- Clear glass vial NylonPrecipitated overnight 21-03 filtered 101-01- LDPE vial NylonPrecipitated overnight 21-04 filtered Nintedanib 101-01- LDPE vial Notfiltered Precipitated overnight esylate + 30 mM 23-01 NaBr Nintedanib101-01- Glass vial Not filtered Precipitated overnight esylate + 30 mM +21-05 1.5% 101-01- LDPE vial Not filtered Precipitated overnightpropylene 21-06 glycol 101-01- 27-03 Nintedanib 101-01- Glass vial Notfiltered No precipitation through 3 esylate + 22-01 months pirfenidone +101-01- LDPE vial Not filtered No precipitation through 3 30 mM NaCl +22-02 months 1.5% 101-01- Glass vial Nylon No precipitation through 3propylene 22-03 filtered months glycol 101-01- LDPE vial Nylon Noprecipitation through 3 22-04 filtered months

Key findings: Clear borosilicate glass vial is not suitable for use withnintedanib esylate, even at low nintedanib esylate concentration of 0.5mg/mL (101-01-23-03 and -04). LDPE vial is suitable for use withnintedanib esylate and with nintedanib esylate in 1.5% propylene glycolsolutions (101-01-24-05 and -05, 101-01-27-02 and -03). Nintedanibesylate, in absence of pirfenidone, is incompatible with NaCl (at 30mM), irrespective of container type and filtration material used(101-01-21-01 through -04, 101-21-05 and -06, 101-01-27-03).Pirfenidone, in combination with propylene glycol, stabilized nintedanibesylate in 30 mM NaCl solution. This formulation can be filled in bothglass and plastic vials (101-01-22-01 through -04).

HBr and HCl salts-filter compatibility study: this study was conductedto assess the compatibility of the HBr and the HCl salts with variousmembrane filters. The Nintedanib salts were dissolved in 3% PG solutionthen filtered through 0.22 μm membrane filters of either nylon,polyester, polytetrafluoroethylene (PTFE) or polyvinylidene fluoride(PVDF) into a clear borosilicate glass vials. The glass vials werestored at ambient room condition and visual appearance was periodicallyinspected. Table 36 shows the visual appearance of the test samples atvarious time points. The HCl sample filtered through the nylon filterand nintedanib HBr filtered through both nylon and PTFE filtersexhibited no change in appearance through 1 month. The HCl and HBrsamples filtered through the PES showed light precipitation after 2weeks at ambient room condition. Samples of both salts filtered throughthe PVDF filters precipitated shortly after filtration, with the HClsalt precipitated more heavily.

TABLE 36 HCl and HBr Salts - Filter Compatibility at Ambient RoomCondition Filter Initial 1 week 2 weeks 1 month Nintedanib HBr saltNylon Clear yellow Clear yellow Clear yellow Clear yellow solutionsolution solution solution Polyester Clear yellow Clear yellow LightLight solution solution precipitation precipitation PTFE Clear yellowClear yellow Clear yellow Clear yellow solution solution solutionsolution PVFD Light Light Light Light precipitation precipitationprecipitation precipitation Nintedanib HCl Salt Nylon Clear yellow Clearyellow Clear yellow Clear yellow solution solution solution solutionPolyester Clear yellow Light Light Light solution precipitationprecipitation precipitation PTFE Clear yellow PrecipitationPrecipitation Precipitation solution PVFD Precipitation PrecipitationPrecipitation Precipitation

-   -   Key findings: Both HBr and HCl salts are compatible with nylon        filter, HBr salt is also compatible with PTFE filters. All other        filters tested have limited compatibility (PES) or no        compatibility with the HBr and HCl salt solutions when stored in        glass vials.

Formulation Screening and Compatibility Studies Summary: Nintedanibesylate cannot be formulated with NaCl (or MgCl₂ or NaBr) as astand-alone, ready to use formulation. Admixing nintedanib esylate in1.5% propylene glycol (for osmolality adjustment) with normal saline (toobtain the required concentration of permeant ion) at the point of useis be necessary to achieve tolerability while maintaining physicalstability of the nintedanib esylate solution through its shelf life.PVDF filter and clear borosilicate glass vials are incompatible withstand-alone nintedanib esylate formulation (i.e. without pirfenidone)while nylon filter and LDPE vials are compatible with both stand-alonenintedanib esylate formulations and nintedanib esylate plus pirfenidonecombination formulations. Pirfenidone and to some extent, propyleneglycol, mannitol and ethanol have a stabilizing effect on nintedanibesylate, enabling a ready-to-use combination formulation nintedanibesylate plus pirfenidone with acceptable osmolality and pH possible.

Nintedanib esylate stand-alone formulation: For stand-alone nintedanibesylate formulation for inhalation, a solution of 1.875 mg/mL nintedanibesylate, 1.875% propylene glycol solution is formulated and packaged inLDPE vials for long term storage. At the point of use, this formulationmay be mixed with normal saline solution at a 4:1 ratio. In otherapplications, this mixture may range from about 1:10 to about 10:1. Theadmixed formulation has 1.5 mg/mL nintedanib esylate, 1.5% propyleneglycol and 30 mM NaCl. The osmolality of this admixed formulation rangesfrom 200-350 mOsm/kg and pH in the range of 3-7. This formulationapproach is taken to ensure that at the point of use that (1) thenintedanib esylate solution has adequate storage shelf life, and (2)upon mixing with normal saline solution, the admixed formulation hasadequate tolerability (from acceptable pH and osmolality perspective)and can be used within one to two hours timeframe.

The composition of the proposed nintedanib esylate-premixed solution andadmixed solution are listed in Table 37.

TABLE 37 Composition of premix nintedanib esylate solution and admixednintedanib esylate formulation and characteristics Target ShelfFormulation Composition/container pH Osmolality Life/Use Life Nintedanib1.875 mg/mL 3-7 150-500 ≥2 years (shelf life) esylate nintedanibesylate, solution 1.875% propylene glycol in LDPE vials Saline 150 mMNaCl 3-7 150-500 ≥2 years (shelf life) solution Admix 4 parts nintedanibesylate solution with 1 part saline solution, mix by inversion Admixed1.5 mg/mL nintedanib 3-7 150-500 mOsm/kg 0-120 min (use life) solutionesylate, 1.5% propylene (4.87 for (268 for (No precipitation glycol, 30mM NaCl formulation formulation within 60 minutes 101-01-13-101-01-13-05) after mixing and 05) during nebulization for formulation101- 01-13-05)

Alternatively, nintedanib salt may be formulated in a ready-useformulation wherein propylene glycol provides sufficient osmolality inthe absence of an additional permeant ion. However, tolerability islimited in the absence of permeant ion addition. Such formulations aredescribed in Table 38 and have been used in animal experimentation.

TABLE 38 Composition of ready-to-use nintedanib salt formulationComposition pH Osmolality Stability 0.5 mg/mL nintedanib HCl, 4.97 283Stable through at least 2 2.0% propylene glycol months at roomtemperature 0.5 mg/mL nintedanib HBr, 4.33 274 Stable through at least 22.0% propylene glycol months at room temperature 0.5 mg/mL nintedanibesylate, 4.86 279 Stable through at least 2 2.0% propylene glycol monthsat room temperature 0.0625 mg/mL nintedanib HCl, 4.88 273 Stable throughat least 2 2.0% propylene glycol months at room temperature 0.25 mg/mLnintedanib HCl, 4.86 278 Stable through at least 2 2.0% propylene glycolmonths at room temperature 1.0 mg/mL nintedanib HCl, 4.77 292 Stablethrough at least 2 2.0% propylene glycol months at room temperature

Nintedanib salt plus pirfenidone combination formulation: Based on theresults of formulation screening and nintedanib esylate compatibilitystudies summarized above, a ready-to-use nintedanib esylate pluspirfenidone combination formulation with an acceptable shelf life can beformulated. This ready to use combination formulation is tolerable forinhalation based on its formulation composition and the expected pH andosmolality. The composition and critical attributes of the proposedready-to-use combination formulation of nintedanib esylate pluspirfenidone are shown in Table 39.

TABLE 39 Composition of ready-to-use nintedanib esylate combinationformulation Composition pH Osmolality Stability 1.5 mg/mL nintedanibesylate, 4.93    328 mOsm/kg Stable through at least 4 12.5 mg/mLpirfenidone, 30 mM months at room temperature NaCl in LDPE or glassvials 1.5 mg/mL nintedanib HCl, 12.5 mg/mL 3-8 150-500 mOsm/kg Stablethrough at least 4 pirfenidone in LDPE months at room temperature

Table 39 describes two ready-to-use formulations. The combinationformation contains permeant ion (in this case chloride, provided fromNaCl), while the single agent nintedanib formulation does not. Permeantion is required for tolerability. Thus, while the single-agentnintedanib formulation is stable in the absence of permeant ion, it isnot well tolerated.

Example 6. Stability of Nintedanib Esylate Formulations

TABLE 40 Stability of Premix Nintedanib Esylate Formulation andReady-to-Use Nintedanib Esylate/Pirfenidone Combination FormulationFormulation % Nintedanib Esylate Remaining (pH) (Formulation 1 month 2month 3 month Number) T0 25° C. 40° C. 25° C. 40° C. 25° C. 40° C. 1.875mg/mL 100.0% 01.1% 100.6% 101.7% 101.7% 101.7% 101.7% Nintedanib (5.26)(4.88) (4.78) (4.87) (4.48) (4.72) (4.66) esylate, 1.875% PG(GP-101-02-30- 01) 1.5 mg/mL 100.0% 102.0% 100.7% 102.0% 101.3% 99.3%100.7% Nintedanib (5.45) (5.30) (5.25) (5.37) (5.09) (5.38) (5.16)esylate, 12.5 mg/mL pirfenidone, 1.5% PG, 30 mM NaCl (GP-101-02-31- 01)

TABLE 41 Stability of Admixed Nintedanib Esylate Formulations withSaline Solution Admixed Admixed stability Formulation Diluentformulation Initial 2 hrs 4 hrs 8 hrs 24 hrs 1.875 mg/mL 0.9% 4 parts %Nintedanib esylate remained post mixing Nintedanib NaCl formulation:100% 100.1% 100.2% 95.0% 93.7% esylate, 1 part Visual appearance 1.875%PG, diluent Clear Clear Clear Yellow Yellow water viscous viscousviscous solution solution yellow yellow yellow with with solutionsolution solution visible more free of free of free of particles visibleparticles particles particles particles

The feasibility of formulating nintedanib esylate formulation foradmixing with saline solution at point of use has been assessed. Thepre-mix nintedanib formulations are stable for at least three months atambient room temperature and accelerated storage conditions (40° C./75%RH). The admixed solution of nintedanib esylate formulation with salineis stable for use for at least four hours.

The ready-to-use combination formulation and pirfenidone (withoutadmixing) is stable at ambient room temperature and accelerated storageconditions for at least three months.

The above results demonstrated that nintedanib esylate is suitable to beformulated as inhalation solution in either ready-to-use form or foradmixing with saline solution at the point of use.

Example 7. Formulation Development and Stability of Nintedanib SaltFormulations

TABLE 42 Feasibility Assessment of Ready-to-Use Nintedanib HBr,Nintedanib HCl and Nintedanib Esylate Formulations Formulation (dateFormulation prepared) Characteristics Stability/Compatibility 0.5 mg/mLNintedanib Clear yellow solution, Nintedanib HBr dissolved slowly, HBr,2% PG pH = 4.27, osmolality = dissolution can be facilitated by heatingin 291 mOsm/kg water bath at 40° C.; formed precipitate on glass wallwhen stored in clear borosilicate glass, does not form precipitates inLDPE vials 0.5 mg/mL Nintedanib Clear yellow solution, Formedprecipitates when stored in clear HCl, 2% PG pH = 5.38, osmolality =glass container, does not form precipitate in 365 mOsm/kg LDPE vial 0.5mg/mL Nintedanib Clear yellow, slightly Changed to pale greenish yellowwith white HCl, 1.5% PG, 30 mM viscous solution, pH = precipitates after30 minutes, no longer NaCl 5.40, osmolality = 278 mOsm/kg viscous 0.5mg/mL Nintedanib Clear yellow, slightly Changed to pale greenish yellowwith white HBr, 1.5% PG, 30 mM viscous solution, pH = precipitates after2 days, no longer viscous NaCl 4.22, osmolality = 267 mOsm/kg 0.5 mg/mLNintedanib Clear yellow solution, Stability not monitored HBr, 2% PG pH= 4.33, osmolality = 274 mOsm/kg 0.5 mg/mL Nintedanib Clear yellowsolution, Stability not monitored HCl, 2% PG pH = 4.97, osmolality = 283mOsm/kg 0.5 mg/mL Nintedanib Clear yellow solution, Stability notmonitored esylate, 2% PG pH = 4.97, osmolality = 283 mOsm/kg 1.5 mg/mLNintedanib Clear yellow solution, Remained clear bright yellow with noHBr, 2% PG, 10 mM pH = 5.5 precipitation after 1 month; several needle-Tris, HCl (to adjust pH like crystals found after 6 months although to5.5) the solution remained clear bright yellow 1.5 mg/mL NintedanibClear yellow solution, Remained clear bright yellow with no HCl, 2% PGpH 5.5 precipitation after 1 month; several needle- 10 mM Tris, HCl (tolike crystals found after 6 months although adjust pH to 5.5) thesolution remained clear bright yellow 1.5 mg/mL NE, 2% Clear yellowsolution Remained clear bright yellow with no PG, 10 mM Tris, HClprecipitation after 1 month; several needle- (to adjust pH to 5.5) likecrystals found after 6 months although the solution remained clearbright yellow 1.5 mg/mL NinBr, 2% Clear yellow solution, Remained clearbright yellow with no PG, 10 mM lysine pH = 5.5 precipitation after 1month; several needle- like crystals found after 6 months although thesolution remained clear bright yellow 1.5 mg/mL Nintedanib Hazy yellowsolution, Remained hazy yellow with light precipitates HCl, 2% PG, 10 mMpH = 5.5 formed overnight lysine, HCl (to adjust pH to 5.5) 1.5 mg/mLNinEs, 2% Clear yellow solution, Remained yellow with light precipitatesPG, 10 mM lysine, HCl pH = 5.5 formed overnight (to adjust pH to 5.5)0.5 mg/mL Nintedanib Clear yellow solution Changed to pale greenishyellow with white HBr, 1.5% PG, 30 mM precipitates after 1 month NaCl 1mg/mL Nintedanib Clear yellow solution Solution remained clear yellowafter 8 HCl, 10 mM HCl months with transparent material coated LDPEcontainer wall 1 mg/mL Nintedanib Clear yellow solution Solution changedto turbid suspension within HCl, 100 mM HCl, 30 minutes with transparentgranular water material coated LDPE container wall 1 mg/mL NintedanibClear yellow viscous Clear viscous yellow solution free of HCl, 10 mMHCl, solution, pH 3.5 precipitates through 6 months glycine (to adjustpH to 3.5) 1 mg/mL Nintedanib Clear yellow solution, Clear bright yellowsolution, with exception HCl, 10 mM HCl pH = 4.0 of a long strand offiber, free of precipitates Glycine (to adjust pH through 6 months to4.0) 1 mg/mL Nintedanib Clear yellow solution, Clear yellow solutionafter 6 months with HCl, 10 mM HCl, pH = 4.5 several needle-likecrystals formed at bottom lysine (to adjust pH to of vials 4.0) 1 mg/mLNintedanib Clear yellow solution, Solution precipitated as pH overshotto 6.24, HCl, 10 mM HCl, pH initial = 6.24, pH pH slowly drifted to 5.12lysine (sufficient final = 5.12 quantity to adjust pH to 6.0) 1 mg/mLNintedanib Viscous clear yellow Solution remained clear yellow with noHCl, 10 mM HCl, 15 mM solution, pH = 4.04 precipitation after 8 months(Jun. 23, 2019) at RT N-acetylcysteine, lysine (quantity sufficient toadjust pH to 4.0) 1 mg/mL Nintedanib Clear yellow, slightly Solutionchanged to pale greenish yellow HCl, 33 mM HCl, 6.1 mg/mL viscoussolution, pH = with white precipitates after 3 hours glycine 3.51 0.735mg/mL lysine 1 mg/mL Nintedanib Clear yellow, slightly Solution changedto pale greenish yellow HCl, 33 mM HCl, 6.1 mg/mL viscous solution, pH =with white precipitates after 3 hours glycine, 1.5 mg/mL 4.21,osmolality = 144 mOsm/kg lysine 1 mg/mL NHBr, 33 mM Clear yellow, slightSolution changed to pale greenish yellow HCl viscous solution, pH = withwhite precipitates within 8 months 6 mg/mL glycine, 4 mg/mL 3.99,osmolality = 146 mOsm/kg tromethamine 0.5 mg/mL Nintedanib Clear yellow,slightly Solution changed to pale greenish yellow HCl viscous solutionwith white precipitates after 2 hours 3% PG, 33 mM NaCl, 1.25% mannitol0.5 mg/mL Nintedanib Clear yellow solution Solution changed to palegreenish yellow HCl with white precipitates after 2 hours 6% PG, 33 mMNaCl, 1.25% mannitol 0.5 mg/mL Nintedanib Clear yellow solution Solutionchanged to pale greenish yellow HCl with white precipitates after 2hours 9% PG, 33 mM NaCl, 1.25% mannitol 0.5 mg/mL Nintedanib Clearyellow solution Solution changed to pale greenish yellow HCl with whiteprecipitates overnight 12% PG, 33 mM NaCl, 1.25% mannitol (Oct. 23,2018) 0.5 mg/mL Nintedanib Clear yellow solution Solution changed topale greenish yellow HCl with white precipitates overnight 15% PG, 33 mMNaCl, 1.25% mannitol 0.5 mg/mL Nintedanib Clear yellow solution Solutionchanged to pale greenish yellow HCl with white precipitates within 2hours 2% PG, 67 mM NaCl 0.5 mg/mL Nintedanib Clear yellow solutionSolution changed to pale greenish yellow HCl, 1.25% PG, 67 mM with whiteprecipitates within 2 hours NaCl 0.25 mg Nintedanib Pale greenish yellowPrecipitation formed immediately when HCl, 150 mM NaCl solution salinesolution is added to dissolved Nintedanib HCl solution 2.75 mg/mL Clearviscous yellow Precipitation appeared after 45 minutes of NintedanibHCl, 33 mM solution preparation NaCl, 12% PG 1.5 mg/mL Nintedanib Clearyellow solution Solution changed to pale greenish yellow HCl, 3% PG, 33mN with white precipitates overnight NaCl, 1.25% mannitol

Neither Nintedanib HBr nor Nintedanib HCl is compatible with NaCl at 30mM or higher concentrations. Nintedanib HCl by itself is not compatiblewith NaCl at 10 mM, but when formulated with glycine orlysine/N-acetylcysteine buffers became compatible Glycine andlysine/N-acetylcysteine may act as a stabilizer to stabilize NintedanibHCl in the presence of NaCl. All formulations containing 1.5 mg/mLNintedanib HBr and Nintedanib HCl that did not form white precipitatesinitially had clear crystals formed within 6 months, indicatingNintedanib HBr and Nintedanib HCl are saturated at 1.5 mg/mLconcentration.

Based on the findings above, further studies were conducted to optimizethe Nintedanib HBr and Nintedanib HCl for long term stability.Excipients considered are PG as osmolality adjusting agent and fumaricacid, glycine, Tris, maleic acid, malic acid, HCl, and NaOH as pHbuffering agents. NaCl was not included due to its effect on thestability of Nintedanib HBr and Nintedanib HCl. These formulations canbe admixed with saline solution at the point of use to achieve optimaltolerability.

As noted above, Osmolality adjusting agents are comprised of consists ofone or more classes of excipients from the following groups: sugars,alcohols, inorganic salts, amino acids, and acids/bases and combinationsthereof. Individually, sugars can be selected from, but not limited to:glucose, fructose, lactose, sucrose, maltose, mannose, trehalose andxylose. Alcohols include but not limited to: erythritol, glycerol,inositol, maltitol, mannitol, menthol, propylene glycol, sorbitol,xylitol, threitol, propylene glycol. Inorganic salts may include but notlimited to: sodium acetate, sodium bromide, sodium chloride, sodiumsulfate, sodium phosphate, sodium carbonate, sodium bicarbonate,potassium carbonate, potassium iodide, potassium chloride, potassiumbromide, magnesium chloride, calcium chloride Amino acids include, butnot limited to: arginine, asparagine, aspartic acid, glutamic acid,glutamine, glycine, histidine, lysine and proline. Finally, acids andbases may include, but not limited to: boric acid, acetic acid, hydrogenbromide, hydrogen chloride, sulfuric acid, nitric acid, phosphoric acid,sodium hydroxide, sodium hydroxide, potassium hydroxide and calciumhydroxide

TABLE 43 Formulation Development/Optimization of Nintedanib HBr andNintedanib HCl and Long-Term Stability Assessment Formulation(Formulation Formulation Number) Characteristics Stability Summary 2.88mg/mL Nintedanib HBr, Clear yellow Solution remained as clear yellowsolution 4% PG solution with needle-like crystals after 1 month;(GP-101-02-55-02) crystalline needles re-dissolved when heated to 50° C.(suggesting crystals formed due to physical change, e.g. precipitationdue to supersaturation, rather than chemical change, e.g., complexation)1.44 mg/mL, Nintedanib HBr, Clear yellow Remained as clear yellowsolution through 7 4.0% PG solution months (GP-101-02-55-03) 2.88 mg/mLNintedanib HBr, Clear yellow Solution remained as clear yellow solution2.5 mg/mL pirfenidone, 4% solution with needle-like crystals (to alesser extent PG than GP-101-02-55-02) after one month;(GP-101-02-55-04) crystals re-dissolved when heated to 50° C. 1.44 mg/mLNintedanib HBr, Clear yellow Remained as clear yellow solution free of1.25 mg/mL pirfenidone, 4% solution precipitates through 7 months PG(GP-101-02-55-05) 0.58 mg/mL, Nintedanib HBr, Clear yellow Remained asclear yellow solution free of 4% PG solution precipitates through 7months (GP-101-02-56-02) 2.76 mg/mL, Nintedanib HBr, Clear yellowSolution remained as clear yellow solution 4% PG solution withneedle-like crystals after 1 month; (GP101-02-60-02) crystalsre-dissolved when heated to 50° C. 1.38 mg/mL Nintedanib HBr, Clearyellow Solution remained clear yellow free of 4% PG solution precipitatethrough 1 month (GP101-02-60-03) 2.76 mg/mL Nintedanib HBr, Clear yellowSolution remained as clear yellow solution 2.4 mg/mL, pirfenidone, 4%solution with needle-like crystals through 1 month; PG crystalsre-dissolved when heated to 50° C. (GP101-02-60-04) 1.38 mg/mLNintedanib HBr, Clear yellow Solution remained clear yellow with no 1.2mg/mL pirfenidone, 4% solution precipitation through 1 month PG(GP101-02-61-01) 1.35 mg/mL Nintedanib HCl Clear yellow Solutionremained clear yellow with no (GP-101-02-63-01) solution precipitationthrough 6 months 1.35 mg/mL Nintedanib HCl, Clear yellow Solutionremained clear yellow with no 3% PG solution precipitation through 6months (GP-101-02-63-02) 0.675 mg/mL Nintedanib HCl Clear yellowSolution remained clear yellow with no (GP-101-02-63-03) solutionprecipitation through 6 months 0.675 mg/mL Nintedanib Clear yellowSolution remained clear yellow with no HCl, 3% PG solution precipitationthrough 6 months (GP-101-02-63-04) 0.338 mg/mL Nintedanib HCl Clearyellow Solution remained clear yellow with no (GP-101-02-63-05) solutionprecipitation through 6 months 0.338 mg/mL Nintedanib Clear yellowSolution remained clear yellow with no HCl, 3% PG solution precipitationthrough 6 months (GP-101-02-63-06) 1.44 mg/mL Nintedanib HBr Clearyellow Crystalline needles formed with 83.8% (GP-101-02-65-01) solutionnintedanib HBr remained after 6 months 1.44 mg/mL Nintedanib HBr, Clearyellow Clear yellow solution with no precipitation; 3.0% PG solution103.1% remained after 6 months (GP-101-02-65-02) 0.72 mg/mL NintedanibHBr Clear yellow Clear yellow solution with no precipitation,(GP-101-02-65-03) solution 108.6% remained after 6 months 0.36 mg/mLNintedanib HBr, Clear yellow Clear yellow solution with noprecipitation; 3.0% PG solution 111.1% remained after 6 months(GP-101-02-65-04) 0.36 mg/mL Nintedanib HBr Clear yellow Clear yellowsolution with no precipitation; (GP-101-02-65-05) solution 101.4%remained after 6 months 0.3125 mg/mL Nintedanib Clear yellow Clearyellow solution with no precipitation; HBr, 3.0% PG solution 102.7%remained after 6 months (GP-101-02-65-06) 0.36 mg/mL Nintedanib HBr,Clear yellow Clear yellow solution with no precipitation; 3% PG solution100.8% remained after 5 months (GP-101-02-70-04) 0.72 mg/mL NintedanibHBr, Clear yellow Clear yellow solution with no precipitation; 3% PGsolution 102.6% remained after 5 months (GP-101-02-70-03) 1.45 mg/mLNintedanib HBr, Clear yellow Clear yellow solution with noprecipitation; 3% PG solution 101.3% remained after 5 months(GP-101-02-70-02) 1.60 mg/mL Nintedanib HBr, Clear yellow Clear yellowsolution with no precipitation; 1.67% PG solution 99.0% remained after 5months at RT (GP-101-02-71-02) 1.53 mg/mL Nintedanib HBr, Clear yellowClear yellow solution with no precipitation 1.67% PG solution after 5months at RT (GP-101-02-72-02) 0.153 mg/mL Nintedanib Clear greenishClear yellow solution with no precipitation HBr, 1.67% PG yellowsolution after 5 months at RT (GP-101-02-72-03) 0.0153 mg/mL NintedanibClear slight Clear yellow solution with no precipitation HBr, 1.67% PGgreenish yellow after 5 months at RT (GP-101-02-73-01) solution 0.8mg/mL Nintedanib HBr, Clear yellow Clear yellow solution with noprecipitation; 1.67% PG solution 106.3% remained after 4 months(GP-101-01-63-02) 0.16 mg/mL Nintedanib HBr, Clear yellow Clear yellowsolution with no precipitation; 1.67% PG solution 108.7% remained after4 months (GP-101-01-63-03) 1.2 mg/mL Nintedanib HBr, Clear yellow Clearyellow solution with no visible 1.67% PG solution particles; 98.4%remained after 4 months (GP-101-01-64-01) 0.2 mg/mL Nintedanib HBr,Clear yellow Stable through 2 months at room temperature 15 mM glycine,2% PG, HCl solution, pH = and 5 C., and 1 month at 50 C.; see stability(to adjust to pH 4.0) 3.96 table 37 (GP-101-02-81-01) 1 mg/mL NintedanibHBr Clear yellow Stable through 2 months at room temperature 15 mMglycine, 2% PG, HCl solution, pH = and 5 C., and 1 month at 50 C.; seestability (to adjust to pH 4.0) 4.02 table 37 (GP-101-02-81-02) 1.25mg/mL Nintedanib HBr, Clear yellow Stable through 2 months at roomtemperature 15 mM glycine, 2% PG, HCl solution, pH = and 5 C., and 1month at 50° C.; see stability (to adjust to pH 4.0) 3.98 table 37(GP-101-02-81-03) 1 mg/mL Nintedanib HBr, Clear yellow Stable through 5weeks at room temperature 15 mM glycine, HCl (to solution, pH = and 5C., and 3 weeks at 50° C.; see stability adjust pH to 4.25), 2% PG 4.19table 37 (GP-101-02-85-03) 1 mg/mL Nintedanib HCl, Clear yellow Seestability table 44 15 mM glycine, HCl (to solution adjust pH to 4.25),2% PG (GP-101-02-85-04) 1 mg/mL Nintedanib HBr, Clear yellow Stablethrough 5 weeks at room temperature 15 mM glycine, HCl (to solution, pH= and 5 C., and 3 weeks at 50° C.; see stability adjust pH to 4.0), 2%PG 4.02 table 44 (GP-101-02-85-05) 1 mg/mL Nintedanib HBr, Clear yellowSee stability table 44 15 mM maleic acid, sodium solution, pH =hydroxide (to adjust pH to 4.63 4.5), 2% PG (GP-101-02-90-02) 1 mg/mLNintedanib HBr, Clear yellow See stability table 44 15 mM glycine,solution, pH = HCl (to adjust pH to 4.25), 4.35 2% PG (GP-101-02-92-01)1 mg/mL Nintedanib HBr, Clear yellow See stability table 44 15 mMglycine, HCl (to solution, pH = adjust pH to 4.25) 4.47(GP-101-02-92-04) 0.2 mg/mL Nintedanib HBr, Clear yellow See stabilitytable 44 15 mM glycine solution, pH = HCl (to adjust pH to 4.25), 4.442% PG (GP-101-02-92-05) 1 mg/mL Nintedanib HBr, Turbid yellow NintedanibHBr did not dissolve in fumarate- 15 mM fumaric acid, Tris (tosuspension Tris buffer solution, heating resulting adjust pH to 4.0)suspension at 50° C. overnight did not (GP-101-02-98-01) dissolveNintedanib HBr 1 mg/mL Nintedanib HBr, Turbid yellow Nintedanib HBr didnot dissolve in fumarate 15 mM fumaric acid, NaOH suspension buffersolution, heating resulting suspension (to adjust pH to 4.0) at 50° C.overnight did not dissolve (GP-101-02-98-02) Nintedanib HBr 1.15 mg/mLNintedanib HBr, Clear yellow See stability table 44 3% PG solution(GP-101-01-69-1) 1.15 mg/mL Nintedanib HBr, Clear yellow, Changed topale greenish yellow with white 15 mM malic acid, Tris (to slightlyviscous precipitates formed overnight adjust pH to 4.0) solution, pH3.89 (GP-101-01-70-02) 0.58 mg/mL Nintedanib HBr, Clear yellowFormulation is not viscous (compared to GP- 15 mM malic acid (pH notsolution 101-01-70-02), remained clear yellow adjusted), 1.5% PG withoutprecipitates through 1 week; see (GP-101-01-70-03) stability table 44 1mg/mL Nintedanib HBr, Clear yellow See stability table 44 15 mM malicacid (pH not solution, pH 2.73, adjusted) 106.3% nominal(GP-101-01-72-01) 1 mg/mL Nintedanib HBr, Clear yellow Remained clearyellow without precipitates 15 mM malic acid, solution, pH 3.5, through1 week; see stability table44 NaOH (to adjust pH to 3.5 103.3% nominal(GP-101-01-72-02) 1 mg/mL Nintedanib HBr, Clear yellow Changed to palegreenish yellow with white 15 mM malic acid, solution, pH 4.0,precipitates formed after four days at RT NaOH (to adjust pH to 4.0)102.8% nominal (GP-101-01-72-03) 1 mg/mL Nintedanib HBr, Clear yellowChanged to pale greenish yellow with white 15 mM malic acid, solution,pH 4.5, precipitates formed overnight NaOH (to adjust pH to 4.5) 11.0%nominal (GP-101-01-73-01) Note: while 15 mM gly-HCl buffer solutionshowed formed white suspending flocculates after 1 week at RT, testsamples containing Nintedanib HBr and 15 mM glycine-HCl buffer have notform any white suspending flocculates through 2 months at RT

TABLE 44 Stability of Selected Nintedanib HBr and Nintedanib HClFormulations Formulation Ambient Room (Formulation 5° C. StorageTemperature 40° C. Storage 50° C. Storage Number) Condition ConditionCondition Condition 0.2 mg/mL 1.5 month: 3 months: 3 months: 1 month:Nintedanib 93.8% 99.6% 98.7% 103.9% HBr, 15 mM glycine, 2% PG, pH 4.0(GP-101-02- 81-01) 1 mg/mL 3 months: 3 months: 98.3% 3 months: 1 month:95.6% Nintedanib 100.2% (pH 4.06) 96.1% HBr, 15 mM glycine, 2% PG, pH4.0 (GP-101-02- 81-02) (1.25 mg/mL 3 months: 3 months: 3 months: 1month: 96.0% Nintedanib 105.1% 100.4% (pH 95.8% HBr, 15 mM 4.06)glycine, 2% PG, pH 4.0 (GP-101-02- 81-03) 1 mg/mL 2 months: 2 months:98.7% 2 months: 3 weeks: Nintedanib 106.6% 101.3% 100.4% HBr, 15 mMglycine, 2% PG, pH 4.25 (GP-101-02- 85-03) 1.25 mg/mL 2 months: 2months: 99.2% 2 months: Not tested Nintedanib 100.1% 102.2% HCl, 15 mMglycine, 2% PG, pH 4.25 (GP-101-02- 85-04) 1.25 mg/mL 2 months: 2months: 2 months: 3 weeks: 97.0% Nintedanib 100.7% 100.5% 100.4% HBr, 15mM glycine, 2% PG, pH 4.0 (GP-101-02- 85-05) 1 mg/mL Precipitated within1 month, stability study terminated Nintedanib HBr, 15 mM maleic acid,2% PG, pH 4.6 (GP-101-02- 90-02) 1 mg/mL 1 months: 1 month: 100.4% 1month: Not tested Nintedanib 101.6% (pH 4.38) 100.7% HBr, 15 mM (pH4.33) glycine, 2% PG, pH 4.35 (GP-101-02- 92-01) 1 mg/mL 1 month: 99.0%1 month: 101.6% 1 month: Not tested Nintedanib (pH 4.60) 101.4% HBr, 15mM (pH 4.51) glycine, pH 4.47 (GP-101-02- 92-04) 0.2 mg/mL 1 month: 1month: 102.3% 1 month: Not tested Nintedanib 100.9% (pH 4.46) 101.8% (pHHBr, 4.33) 15 mM glycine, 2% PG, pH 4.44 (GP-101-02- 92-05) 1.15 mg/mL 1month: 1 month: 103.0% 1 month: Not tested Nintedanib 102.0% 102.3% HBr,3% PG, water, pH 4.0 (GP-101-01- 69-01) 1.15 mg/mL Precipitated within 1month, stability study terminated Nintedanib HBr, 15 mM malic acid,Tris, pH 4.0 (GP-101-01- 70-01) 0.58 mg/mL Precipitated within 1 month,stability study terminated Nintedanib HBr, 7.5 mM malic acid, 1.5% PG,(GP-101-01- 70-02) 1 mg/mL Precipitated within 1 month, stability studyterminated Nintedanib HBr, 15 mM malic acid (GP-101-01- 72-01) 1 mg/mLPrecipitated within 1 month, stability study terminated Nintedanib HBr,15 mM malic acid, pH adjusted to 3.5 (GP- 101-01-72- 02) 1 mg/mLPrecipitated within 1 month, stability study terminated Nintedanib HBr,15 mM maleic acid, pH adjusted to 4.0 (GP-101-01- 72-03) 1 mg/mLInitial: 11.0% Nintedanib Stability terminated due to precipitation HBr,15 mM maleic acid, pH adjusted to 4.5 (GP-101-01- 72-04)

Nintedanib HBr and HCl concentrations at or above 1.44 mg/mL formedneedle-like crystals over time. Heating the precipitated samples at 50°C. re-dissolved the crystals, indicating that precipitation is due toover-saturation and re-crystallization of Nintedanib HBr or NintedanibHCl. Formulations prepared with Nintedanib HBr or Nintedanib HClconcentrations at or below 1.38 mg/mL showed no re-crystallization,suggesting 1.38 mg/mL as the upper concentration limit.

Nintedanib HBr and Nintedanib HCl, like Nintedanib esylate, arecompatible with PG, glycine, pirfenidone and water. Furthermore,Nintedanib HBr and Nintedanib HCl are also compatible with glycine,lysine/N-acetylcysteine, maleate, mannitol, and Tris. Nintedanib HBr andNintedanib HCl are incompatible with citric acid, fumaric acid, and havelimited compatibility with malic acid (pH dependent). Glycine, on theother hand, by itself forms white flocculates at ambient roomtemperature within 2 weeks, is stabilized by Nintedanib HBr andNintedanib HCl. In formulations containing Nintedanib HBr and NintedanibHCl tested through approximately 2 months, glycine does not formflocculations.

While most of the formulations listed above are suitable for directnebulization (pH 3-8, osmolality 150-500), due to the absence or lowconcentrations of permeant ions (Cl— or Br—), airway irritation is foundin certain patients. To achieve optimal airway tolerability while stillmaintaining acceptable in-use stability (≥2 hours post mixing), as inthe case of nintedanib esylate, Nintedanib HBr and Nintedanib HCl can beadmixed with saline solution to produce chloride concentration in theadmixed solution at 10 mM, more preferably 30 mM and most preferably 40mM. Tables 45 and 46 shows the characteristics and in-use stability ofvarious admixed Nintedanib HBr and Nintedanib HCl formulations withsaline solution.

TABLE 45 Characteristics of Admixed Nintedanib HBr Formulations withSaline Solution Formulation Characteristics of (Formulation AdmixedAdmixed Formulation Number) Diluent formulation pH Osmolality 2.89 mg/mL0.8% 1 part 4.04 417 mOsm/kg Nintedanib HBr, NaCl formulation: 4% PG 1part diluent (GP-101-02-55- 02) 1.44 mg/mL 0.8% 1 part 4.36 411 mOsm/kgNintedanib HBr, NaCl formulation: 4.0% PG 1 part diluent (GP-101-02-55-03) 2.89 mg/mL 0.8% 1 part 4.12 411 mOsm/kg Nintedanib HBr, NaClformulation: 2.5 mg/mL 1 part diluent pirfenidone, 4% PG (GP-101-02-55-04) 1.44 mg/mL 0.8% 1 part 4.46 419 mOsm/kg Nintedanib HBr, NaClformulation: 1.25 mg/mL 1 part diluent pirfenidone, 4% PG (GP-101-02-55-05) 0.578 mg/mL 0.8% 1 part 4.61 412 mOsm/kg Nintedanib HBr, NaClformulation: 4% PG 1 part diluent (GP-101-02-56- 02)

TABLE 46 Stability of Nintedanib HBr admixed solutions with salinesolution at Various Mixing Ratios Formulation Composition of(Formulation Admixed Number) Diluent Mixing Ratio Solution VisualStability 1.25 mg/mL 1.8% 4 parts 1 mg/mL Clear viscous yellow solutionNintedanib HCl NaCl formulation: Nintedanib HCl free of particles thatremained 1.56% mannitol 1 part diluent 1.25% mannitol unchanged after 4hours of 1.875% PG 1.5% PG, admixing (10-10-18) 0.36% NaCl 0.16 mg/mL 4%9 parts 0.144 mg/mL No visual change in admixed Nintedanib HBr, NaClformulation: Nintedanib solution through 3 hours 1.67% PG 1 part diluentHBr, 1.5% PG, (GP-101-01-63- 0.4% NaCl 03) 0.8 mg/mL 4% 9 parts 0.72mg/mL No visual change in admixed Nintedanib HBr, NaCl formulation:Nintedanib solution through 3 hours 1.67% PG 1 part diluent HBr, 1.5%PG, (GP-101-02-63- 0.4% NaCl 02) 1.2 mg/mL 4% 9 parts 1.08 mg/mL Novisual change in admixed Nintedanib HBr, NaCl formulation: Nintedanibsolution through 3 hours 1.67% PG 1 part diluent HBr, 1.5% PG,(GP-101-02-64- 0.4% NaCl 01) 1.44 mg/mL 0.9% 5 parts 0.8 mg/mL A thinstrand of light Nintedanib HBr, NaCl formulation: Nintedanibprecipitates appear after 2 3% PG 4 parts diluent HBr, 1.67% PG, hoursof admixing, admixed (GP-101-02-70- 0.4% NaCl solution remained slight02) viscous and clear bright yellow 0.675% 5 parts 0.8 mg/mL No visualchange within NaCl formulation: Nintedanib 2hours after admixing, faint4 parts diluent HBr, 1.67% PG, precipitation observed at 3 0.3% NaClhours 0.45% 5 parts 0.8 mg/mL No visual change in admixed NaClformulation: Nintedanib solution after 2 hours, faint 4 parts diluentHBr, 1.67% PG, appearance of fine crystals 0.2% NaCl when viewed underbright light after 3 hours 1.04 mg/mL 0.9% 5 parts 0.58 mg/mL No visualchange in admixed Nintedanib HBr, NaCl formulation: Nintedanib solutionafter 2 hours, faint 2.7% PG 4 parts diluent HBr, 1.5% PG, appearance offine crystals (GP-101-02-75- 0.4% NaCl when viewed under bright light02) after 3 hours 0.675% 5 parts 0.58 mg/mL No visual change in admixedNaCl formulation: Nintedanib solution after 2 hours, faint 4 partsdiluent HBr, 1.5% PG, appearance of fine crystals 0.3% NaCl when viewedunder bright light after 3 hours 0.45% 5 parts 0.58 mg/mL No visualchange in admixed NaCl formulation: Nintedanib solution after 2 hours,faint 4 parts diluent HBr, 1.5% PG, appearance of fine crystals 0.2%NaCl when viewed under bright light after 3 hours 0.26 mg/mL 0.9% 5parts 0.14 mg/mL No visual change within 75 Nintedanib HBr, NaClformulation: Nintedanib minutes of admixing, faint 2.7% PG 4 partsdiluent HBr, 1.5% PG, precipitation observed at 90 (GP-101-02-75- 0.4%NaCl minutes, more apparent after 2 04) hours 0.675% 5 parts 0.14 mg/mLNo visual change within 2.5 NaCl formulation: Nintedanib hours afteradmixing, faint 4 parts diluent HBr, 1.5% PG, precipitation observed at3 0.3% NaCl hours 0.45% 5 parts 0.14 mg/mL No visual change after 3hours NaCl formulation: Nintedanib 4 parts diluent HBr, 1.5% PG, 0.2%NaCl 0.2 mg/mL 1.6% 3-parts 0.15 mg/mL Clear viscous yellow solutionNintedanib HBr, NaCl formulation: Nintedanib HBr through 2 hours postadmixing; 15 mM glycine, 1 part diluent 11.25 mM precipitates firstbecame 2% PG, pH 4.0 glycine, visible 2 hours after admixing(GP-101-02-81- HCl Initial pH = 4.01; 01) after 2 hours pH = 4.09;Placing precipitated admixed solution from above in a 50° C. water bathreturned solution to clear bright yellow precipitate free; Freshlyprepared admixed solution kept in 50° C. water bath also remainedprecipitate free through 12 hours 1 mg/mL 1.6% 3 parts 0.75 mg/mL T0post mixing: pH = 3.99, no Nintedanib HBr, NaCl formulation: Nintedanibprecipitate; 2% PG, 15 mM 1part diluent HBr, 1.5% PG, 15 min: pH = 4.07,no glycine, pH 4.0 11.3 mM precipitate; (GP-101-02-81- glycine 1 hr: pH= 4.08, no precipitate; 02) 2 hrs: pH = 4.08 no precipitate; 3 hrs: pH =4.09, precipitates first visible; 8 hrs: pH = 4.08, solution changed topale greenish yellow solution with white precipitates; Freshly preparedadmixed solution kept in 50° C. water bath remained precipitate freethrough 12 hours 1.5 mg/mL 1.6% 3 parts 0.94 mg/mL T0 post mixing: pH =4.00, no Nintedanib HBr, NaCl formulation: 1 Nintedanib precipitate; 2%PG, 15 mM part diluent HBr, 1.5% PG, 15 min: pH = 4.06, no glycine, pH4.0 11.3 mM precipitate; (GP-101-02-81- glycine 1 hr: pH = 4.08, noprecipitate; 03) 2 hrs: pH = 4.07 precipitates first observed; 3 hrs: pH= 4.07, precipitates more visible; Placing the admixed solution fromabove into 50° C. water bath returned the solution to clear brightyellow with no precipitations; Freshly prepared admixed solution kept in50° C. water bath remained precipitate free through 12 hours

The above admixed formulations of Nintedanib HBr and Nintedanib HCl withsaline solution have acceptable pH (3-8), osmolality (150-500 mOsm/kg)to be delivered as aerosol for oral inhalation. These admixedformulations are shown to have adequate in-use stability (at least 2hours and can be up to 3-4 hours). The admixed formulation can be kepteven longer if maintained in a 50° C. condition for at least 12 hours.

With adequate controls using appropriate type of containers, type offilters, type of buffering agents and amount of permeant ions,nintedanib salts can be formulated as ready-to-use or for admixing withsaline solution with acceptable shelf life and in-use stability.

Nintedanib esylate with sodium chloride admixed solutions and nintedanibhydrobromide with sodium chloride admixed solutions at different sodiumchloride concentrations were assessed for post admixing stability.Nintedanib esylate and nintedanib hydrobromide at 0.5 mg/mL (calculatedas freebase) were formulated in 15 mM glycinate buffer at pH 4.0containing 3% propylene glycol. These solutions were admixed with sodiumchloride solution at different concentrations at 1:1 ratio to form 0.25mg/mL nintedanib solution (expressed as freebase), 7.5 mM glycinatebuffer, 1.5% propylene glycol, and either 0.2%, 0.3% or 0.4% NaCl. Theadmixed solutions were visually inspected for visual appearance andpresence of precipitates, an indicator for physical instability. Thestability results are summarized in Table 47 below.

TABLE 47 Stability of nintedanib esylate/sodium chloride and nintedanibhydrobromide/sodium chloride admixtures Time after Nintedanib esylate/Nintedanib hydrobromide/ admixing NaCl admixture NaCl admixture (hours)0.2% NaCl 0.3% NaCl 0.4% NaCl 0.2% NaCl 0.3% NaCl 0.4% NaCl 1 Clearyellow Clear yellow Clear yellow Clear yellow Clear yellow Clear yellow1.5 Clear yellow Faint Faint Clear yellow Clear yellow Clear yellowprecipitation precipitation 2 Clear yellow Precipitated PrecipitatedClear yellow Clear yellow Faint precipitation 2.5 Clear yellowPrecipitated Precipitated Clear yellow Clear yellow Precipitated 4 Clearyellow Precipitated Precipitated Clear yellow Clear yellow Precipitated6 Faint Precipitated Precipitated Clear yellow Faint Precipitatedprecipitation precipitation

The data shows that solution stability of both nintedanib esylate andnintedanib hydrobromide admixtures decrease with increasing NaClconcentration. At a given NaCl concentration, nintedanib hydrobromideadmixture is more stable in solution than the nintedanib esylateadmixture. Greater than 1 hour admixture stability is clinicallyimportant to allow sufficient time for the patient to perform theadmixture and administer the given dosage. Nebulized dosing solutionscontaining at least 0.3% NaCl are most well-tolerated. The nintedanibhydrobromide admixture meets both of these requirements.

Example 8: Pharmacokinetics and Lung-Tissue Distribution

To characterize and compare nintedanib plasma and lung pharmacokineticsfollowing oral and inhaled administration, six-week-old female C57BL/6mice (18-20 gram) were administered nintedanib esylate by oral (gavage;PO) or direct-lung aerosol delivery (intratracheal; Penn CenturyMicroSprayer® nebulizing catheter; IT). For oral administration, 100mg/kg nintedanib esylate (120 mg/kg esylate salt form) was dissolved in1% methylcellulose and delivered by gavage. Plasma and lung tissuesamples were taken at 2, 5, 10, 20, 40 min and 1, 2, and 4 hours postdose. Nintedanib was extracted and quantitated as μg/mL plasma andμg/gram lung tissue. For IT aerosol administration, 2.5 and 10 mg/kgnintedanib esylate (3.0 and 12 mg/kg esylate salt form) was formulatedin 0.050 mL 2% propylene glycol and delivered directly to the lung bynebulizing catheter. Plasma and lung tissue samples were taken 2, 5, 10,20, 40 min and 1, 2, and 4 hours post dose. Nintedanib was extracted andquantitated as μg/mL plasma and μg/gram lung tissue. Results from thesestudies are shown in Table 48.

TABLE 48 Pharmacokinetics of nintedanib esylate oral and intratrachealformulations Dose Drug (mg/kg) Route^(a) Matrix^(b) Cmax^(c)Half-life^(d) AUC^(e) Nintedanib 100.0 PO Plasma 0.6 112 1.8 esylateLung 12.1 ND 24.1 2.5 IT Plasma 0.7 2.3 0.2 Lung 57.5 3.8 67.8 10.0Plasma 2.7 2.3 0.6 Lung 250.0 5.6 167.8 ^(a)IT: Intratracheal; ^(b)Lung:Whole lung homogenate; ^(c)plasma: mcg/mL; lung: mcg/gram;^(d)Elimination half-life (alpha-phase in minutes); ^(e)AUC: Area underthe curve 0-last (plasma: mg · hour/L; lung: mg · hour/kg)

Results indicate that 2.5 and 10 mg/kg direct lung administerednintedanib doses result in about 5-fold and about 20-fold greater lungCmax than 100 mg/kg delivered orally. Results also show that 2.5 and 10mg/kg direct lung administered nintedanib doses result in about 3-foldand about 7-fold greater lung AUC than 100 mg/kg delivered orally.Hence, much small inhaled nintedanib doses deliver superior criticallung pharmacokinetic parameters compared to much larger oral doses. Morespecifically, it can be calculated that about 200-fold less ITnintedanib will achieve the same lung Cmax was achieved following oraldelivery (12.1 mcg/gram oral lung Cmax divided by 57.5 mcg/gram 2.5mg/kg IT Cmax=0.21. 0.21 times 2.5 mg/kg IT dose=0.5 mg/kg IT comparedto 100 mg/kg oral). As these lung-delivered Cmax levels are relativelyshort-lived, important for inhaled product success was the Example 2demonstration that only short-duration nintedanib peak levels arerequired for maximum nintedanib activity. An oral-equivalent inhalednintedanib lung Cmax will result in oral-equivalent efficacy such thatmuch less inhaled drug is required for equivalent efficacy; smallinhaled nintedanib dose levels enable improved safety and tolerability.Improving the safety and tolerability of nintedanib by inhalationadministration effectively broadens the nintedanib therapeutic index(TI).

For systemic exposure, results indicate that 2.5 mg/kg and 10 mg/kginhaled nintedanib results in plasma Cmax levels that are equivalent andabout 5-fold that of the 100 mg/kg oral dose, respectively, and plasmaAUCs that are about 1/9th and ⅓rd that of the 100 mg/kg oral dose,respectively. Taken together, these results show promise for inhalationto improve lung dose with reduced systemic exposure. Because nintedanibside effects are largely due to gastrointestinal exposure and drug-bloodlevels, achieving high lung levels in the absence of high blood levelsoffers potential for improved pulmonary efficacy with fewer sideeffects. In this study 10 mg/kg nintedanib esylate salt caused dyspneain the IT-delivered animals This adverse effect was not observed at 2.5mg/kg.

To characterize and compare the plasma and lung pharmacokinetic profilesof inhaled nintedanib and inhaled pirfenidone when administered infixed-combination, six-week-old female C57BL/6 mice (18-20 gram) wereadministered a combined nintedanib esylate and pirfenidone formulationby direct-lung aerosol delivery (intratracheal; Penn CenturyMicroSprayer® nebulizing catheter; IT). For IT aerosol administration,10 mg/kg nintedanib esylate (12 mg/kg esylate salt form) wasco-formulated with 10 mg/kg pirfenidone in 0.050 mL 2% propylene glycoland delivered directly to the lung by nebulizing catheter. Plasma andlung tissue samples were taken 2, 5, 10, 20, 40 min and 1, 2, and 4hours post dose. Nintedanib was extracted and quantitated as μg/mLplasma and μg/gram lung tissue. Results from these studies are shown inTable 49.

TABLE 49 Inhaled pharmacokinetics of fixed combination nintedanibesylate and pirfenidone formulation Dose Drug (mg/kg) Route^(a)Matrix^(b) Cmax^(c) Half-life^(d) AUC^(e) Nintedanib 10.0 IT Plasma 2.87.7 1.0 esylate Lung 171.1 1.8 68.4 Pirfenidone 10.0 Plasma 7.9 8.9 3.8Lung 279.0 0.7 5.2 ^(a)IT: Intratracheal; ^(b)Lung: Whole lunghomogenate; ^(c)mcg/mL; ^(d)Elimination half-life (alpha-phase inminutes); ^(e)AUC: Area under the curve 0-last (plasma: mg · hour/L;lung: mg · hour/kg)

Results indicate that a fixed combination of nintedanib and pirfenidonecan be co-formulated and co-administered directly to the lung of ananimal. Results indicate that administration results in pirfenidonehaving a higher lung and plasma Cmax than nintedanib, with nintedanibhaving a lower elimination half-life resulting in a much larger lungAUC.

To characterize and compare the pharmacokinetic profiles of variousinhaled nintedanib salt forms, six-week-old female C57BL/6 mice (18-20gram) were administered either nintedanib esylate, nintedanibhydrochloride or nintedanib hydrobromide by direct-lung aerosol delivery(intratracheal; Penn Century MicroSprayer® nebulizing catheter; IT). ForIT aerosol administration and calculated on a base equivalent, 1 mg/kgof each salt was formulated in 0.050 mL 2% propylene glycol anddelivered directly to the lung by nebulizing catheter. Plasma and lungtissue samples were taken 2, 5, 10, 20, 40 min and 1, 2, 3 and 4 hourspost dose. Nintedanib was extracted and quantitated as μg/mL plasma andμg/gram lung tissue. Results from these studies are shown in Table 50.

TABLE 50 Inhaled pharmacokinetics of various nintedanib salt forms DoseSalt (mg/kg) Route^(a) Matrix^(b) Cmax^(c) Half-life^(d) AUC^(e)Nintedanib 1.0 IT Plasma 0.4 2.0 0.2 esylate Lung 34.5 2.9 21.7Nintedanib Plasma 0.4 1.7 0.2 chloride Lung 34.4 3.9 60.1 NintedanibPlasma 0.2 2.4 0.2 bromide Lung 30.6 4.1 51.2 ^(a)IT: Intratracheal;^(b)Lung: Whole lung homogenate; ^(c)mcg/mL; ^(d)Elimination half-life(alpha-phase in minutes); ^(e)AUC: Area under the curve 0-last (plasma:mg · hour/L; lung: mg · hour/kg)

Results indicate that each salt is efficiently delivered to the lung andachieve a similar lung and plasma Cmax. While plasma half-life and AUCswere also similar between the salts, lung half-life varied (half-lifesof about 4 minutes for nintedanib hydrochloride and hydrobromide, butabout 3 minutes for nintedanib esylate). This variance also contributesto lung AUC where the hydrochloride and hydrobromide salt forms werebetween about 50 and 60 mg·hr/kg, whereas the esylate salt was about 20mg·hr/kg. While nintedanib efficacy appears to be concentrationdependent, such prolonged lung half-lives for the hydrochloride andhydrobromide salts also contributes to therapeutic effect (longer lungexposure) compared to the esylate salt form. All salts werewell-tolerated at these dose levels.

TABLE 51 Human inhaled dose projection Plasma Lung Ofev (150 mg oral)Cmax (μg/mL or μg/g) 0.029 0.014 AUC (mg · hr/L or mg · hr/kg) 0.1740.087 Inhaled nintedanib (0.42 mg device loaded dose^(a)) Cmax (μg/mL orμg/g) 0.024 0.364 AUC (mg · hr/L or mg · hr/kg) 0.174 0.911 %Pharmacokinetics (inhaled compared to oral) Cmax 83 2600 AUC 100 1047^(a)Assumes 67% loaded drug is inhaled (inhaled mass) and that 78% ofaerosol particles in the inhaled mass are less than 5 μm in diameter.

Table 51 results indicate that a 0.42 mg device loaded nintedanib dosewill delivers an inhaled dose resulting in the same plasma AUC as a 150mg oral dose, with a 2600% (26-fold) greater nintedanib lung Cmax than a150 mg oral dose, and a 1047% (10.47-fold) greater nintedanib lung AUC.Under the assumption that plasma AUC drives oral nintedanib sideeffects, this 0.42 mg device loaded nintedanib dose will deliver thesame side effects as the 150 mg oral dose. Under this scenario, this maybe assumed as the highest dose. This projected highest dose may then bedose de-escalated to a more-well-tolerated dose level while maintainingsuperior lung levels. By example, with lung Cmax as the target, thisoral-equivalent plasma AUC dose delivers 26-fold more lung Cmax. Thismay then be dose de-escalated up to 26-fold while maintaining alung-equivalent or superior Cmax. Similarly, with lung AUC as thetarget, this dose may be dose de-escalated about 10- to 11-fold whilemaintaining a lung-equivalent or superior AUC. Clinical dose escalationwill confirm or modify these dose and pharmacokinetic predictions.

Example 9: Nebulization Device Performance

To evaluate aerosol performance, several nintedanib salt formulations(Table 30, formulations 380 and 381) were tested in the eFlow device. Inaddition, a formulation combining pirfenidone and nintedanib HCl wasalso tested. For these studies the standard eFlow 35L head was used.Particle size distribution was determined using a Malvern Spraytec laserparticle sizer. Results are shown in Table 52. Each result is an averageof duplicate trials in each of three devices.

TABLE 52 Nebulized aerosol particle sizing Formulation (Table 24):Formulation Nintedanib Salt form HCl HBr Esylate HCl Nintedanib mg/mL1.5 1.5 1.5 1.5 Pirfenidone mg/mL 0.0 0.0 0.0 12.5 Fill volume mL 1.01.0 1.0 1.0 Duration min 2.7 2.5 2.3 2.1 ≤1 μm % 0.0 0.0 0.0 0.0 ≤3 μm15.4 13.8 12.5 14.4 ≤5 μm^(a) 61.5 58.1 54.9 61.4 GSD 1.4 1.4 1.4 1.4Dv(50)^(b) % <5 μm 4.5 4.6 4.8 4.5 Nebulized dose^(c) mg 811.7 794.7752.3 751.2 TOR^(d) mg/min 324.7 327.5 337.5 377.0 FPD^(e) mg 499.2461.7 413.0 461.2 FPD output rate mg/min 195.8 188.5 185.6 231.4Residual delivered mg 139.8 177.0 231.2 207.8 dose ^(a)Percent nebulizedparticles <5 μm (also known as respirable fraction; RF); ^(b)Maximumparticle diameter below which 50% of the sample volume exists; ^(c)mgaerosol emitted from device; ^(d)Total output rate or nebulized dose permin; ^(e)Fine particle dose or mg nebulized dose particles <5 μm

Table 52 results show that 1.0 mL of a 1.5 mg/mL nintedanib formulationwill be administered in about 2.5 minutes and produced a fine particledose (mg dose present within inhaled aerosol particles less than 5microns (μm) in diameter; FPD) of about 0.46 mg; a nebulizationefficiency of about 31%. Manipulation of the nintedanib concentrationand device fill volume will permit optimization of dose delivery timeand lung/plasma exposure ratio. By example, a high nintedanibconcentration formulation will be administered in only a few breathsover a short time. The result will be a higher lung Cmax with the sameplasma exposure as the same amount of nintedanib delivered in a largervolume over more breaths and longer time. Similarly, if the resultingplasma Cmax is determined to be of concern, this is addressed by eitherless administered nintedanib or a lower concentration nintedanibformulation. Both will reduce lung Cmax, but permit balancing the twocritical parameters.

Example 10: Inhaled Nintedanib Salt In Vivo Pharmacology—TherapeuticBleomycin Model

To evaluate the in vivo activity of inhaled nintedanib, the therapeuticbleomycin pulmonary fibrosis model was performed. Briefly, acclimatedSprague Dawley male rats (c.a. 253 grams at first dosing) wereadministered bleomycin on days 1, 2, 3 and 6 by the oropharyngeal (OP)route. On the eighth day, treatment was initiated with either saline ornintedanib. Inhaled nintedanib formulations were delivered by OPadministration. Preliminary experiments showed good lung delivery anddistribution by this method. On days 8 through 27, OP animals wereanesthetized with isoflurane and dosed once a day (QD) with either 0.05,0.25 or 0.375 mg/kg nintedanib HBr formulation (Table 53). Oralgavage-treated (PO) animals were dosed twice a day (BID) with 60 mg/kgnintedanib esylate in water Sham and bleomycin control groups receivedsaline either OP or PO. Ten animals were enrolled into each dosinggroup. For OP nintedanib administration, doses were selected to deliverPO-inferior, -equivalent and -superior lung Cmax and AUC (Table 54). Allanimals were euthanized on day 28d. Body weights were collectedthroughout the study, with lung weights at termination (Table 55). Leftlungs were extracted and measured for hydroxyproline content, while leftlungs were subjected to histology for Ashcroft fibrosis scoredetermination (Table 56).

TABLE 53 Oropharyngeal formulations and admixed dosing solutioncompositions Solution Compositions Admixed Dosing Route Dose LevelSolution 1 Solution 2 Solution (9:1)^(a) Oropharyngeal Vehicle −1.67%propylene 4.0% NaCl −1.5% propylene (OP) glycol glycol −0.4% NaCl 0.05mg/kg −0.14 mg/mL 4.0% NaCl −0.125 mg/mL nintedanib nintedanibnintedanib −1.67% propylene −1.5% propylene glycol glycol −0.4% NaCl0.25 mg/kg −0.69 mg/mL 4.0% NaCl −0.625 mg/mL nintedanib nintedanibnintedanib −1.67% propylene −1.5% propylene glycol glycol −0.4% NaCl0.375 mg/kg −1.04 mg/mL 4.0% NaCl −0.938 mg/mL nintedanib nintedanibnintedanib −1.67% propylene −1.5% propylene glycol glycol −0.4% NaCl^(a)Expressed as nintedanib free base

TABLE 54 Bleomycin dose levels and pharmacokinetic comparison Dose LungCmax Lung AUC Route (mg/kg) (μg/g) (mg · hr/kg) Oropharyngeal (OP) 0.051.4 1.6 0.25 7.0 7.8 0.375 10.5 11.6 Oral Gavage (PO) 60.0 4.4 29.3

Oropharyngeal (OP) dose levels were selected by comparing lungpharmacokinetics following OP dosing to lung pharmacokinetics determinedfollowing 60 mg/kg oral gavage (PO). By this comparison, 0.05 wasselected to deliver lung Cmax and AUC lower than that delivered by 60mg/kg PO, 0.25 mg/kg was selected to deliver an equivalent Cmax as 60mg/kg PO, and 0.375 mg/kg was selected to deliver a lung Cmax greaterthan 60 mg/kg PO. It should be noted that preliminary assessment showedthat 0.5 mg/kg OP was not well tolerated by bleomycin-exposed animals,hence the well-tolerated 0.375 mg/kg was selected as the highest OPdose.

TABLE 55 Animal weight gain and lung weight-body-weight ratios Lungweight-to-body Body Weight weight Delta to Delta to Gain (g) Sham ShamRoute Dose Group (SD) (%) Ratio (SD) (%) Oropharyngeal Sham 132.0 0.00.392 0.0 (OP) (37.7) (0.031) Vehicle 107.6 −18.5 0.493 25.8 (25.6)(0.055)  0.05 mg/kg 107.7 −18.4 0.526 34.2 (28.5) (0.063)  0.25 mg/kg96.8 −26.7 0.476 21.4 (18.9) (0.036) 0.375 mg/kg 127.0 −4.8 0.466 18.9(34.0) (0.022) Oral Gavage Sham 126.8 0.0 0.399 0.0 (PO) (22.3) (0.027)Vehicle 128.7 1.9 0.483 21.1 (33.8) (0.038)   60 mg/kg 67.4 −46.9 0.45514.0 (28.8) (0.032)

Animal body weight results indicate the following: 1. Inhaled (OP) dosegroup animals exposed to both bleomycin and isoflurane exhibited lessweight gain than sham animals receiving isofluorane without bleomycin;2. High dose OP resulted in weight gain equivalent to sham animals; 3.Oral (PO) nintedanib dosed animals gained about half the weight ofcontrol animals; and 4. Bleomycin exposure (vehicle control groupanimals) resulted in an ˜20% increase in lung-to-body weight ratio oversham animals. Both OP showed a dose responsive reduction in lung-to-bodyweight ratio. PO administration also reduced lung-to-body weight ratio.

TABLE 56 Animal lung fibrosis scores (Ashcroft) Fibrosis Score Delta toVehicle Route Dose Group (SD) (%) Oropharyngeal Sham 0.1 (0.11) 100.0(OP) Vehicle 2.4 (1.04) 0.0  0.05 mg/kg 2.7 (0.94) −12.5  0.25 mg/kg 2.1(0.97) 12.5 0.375 mg/kg 1.9 (0.48) 20.8 Oral Gavage (PO) Sham 0.0 (0.00)100.0 Vehicle 2.6 (0.70) 0.0   60 mg/kg 2.3 (0.45) 11.5

Lung fibrosis score results indicate the following: 1. Inhaled (OP) dosegroup animals showed a dose responsive reduction in fibrosis score; 2.The inhaled low dose (less lung-delivered nintedanib Cmax and AUC thanoral) resulted in less anti-fibrotic activity than oral, the inhaledmid-dose (similar lung-delivered nintedanib Cmax and lower AUC thanoral) resulted in an equivalent amount of anti-fibrotic activity asoral, and the inhaled high dose (more lung-delivered nintedanib Cmax andlower AUC than oral) resulted in more anti-fibrotic activity as oral; 3.High dose OP resulted in weight gain equivalent to sham animals; 3. Oral(PO) nintedanib dosed animals gained about half the weight of controlanimals; and 4. Bleomycin exposure (vehicle control group animals)resulted in an ˜20% increase in lung-to-body weight ratio over shamanimals. Both OP showed a dose responsive reduction in lung-to-bodyweight ratio. PO administration also reduced lung-to-body weight ratio.

Compared to oral, inhalation was superior to equivalent in all keyfibrosis measurements. At oral-equivalent lung exposures, inhalationshowed similar results (at 1/240 the dose) in key fibrosis measures. Athigher lung exposure, treatment was more effective (at 1/160 the dose).

Example 11: Inhaled Nintedanib Salt In Vivo Pharmacology—TherapeuticSilica Model

To evaluate the in vivo activity of inhaled nintedanib, the therapeuticsilica pulmonary fibrosis model was performed. Briefly, acclimated 20-22g female C57BL/6 mice were administered silica on day 1 by theintratracheal route. On the tenth day, treatment was initiated witheither saline or nintedanib. Inhaled nintedanib formulations (35 pt perdose) were delivered by intranasal (IN) administration. Preliminaryexperiments showed good lung delivery and distribution by this method.On days 10 through 29, IN animals were anesthetized with isoflurane anddosed once a day (QD) with either 0.021, 0.21 or 2.1 mg/kg nintedanibHBr formulation (Table 57). Oral gavage-treated (PO) animals were dosedtwice a day (BID) with 30 mg/kg nintedanib HBr in water. Sham and silicacontrol groups received saline either IN or PO. Five animals wereenrolled into sham groups, 10 animals enrolled into each PO dose groups,and 13 animals were enrolled into each IN dosing group. For INnintedanib administration, doses were selected to deliver PO-inferior,equivalent and superior lung Cmax and AUC (Table 58). All animals wereeuthanized on day 30d. Body weights were collected throughout the study,with lung weights at termination. Flexivent was performed to determineelastance (lung function; Table 59). Left lungs were extracted, stainedas assessed for parenchymal collagen (Table 60) and cc-smooth muscleactin (αSMA; Table 61), while right lungs were assessed forinterleukin-1β (IL-1β; Table 62).

TABLE 57 Intranasal formulations and admixed dosing solutioncompositions Solution Compositions Admixed Dosing Route Dose LevelSolution 1 Solution 2 Solution (9:1)^(b) Intranasal (IN) Vehicle −1.67%propylene 4.0% NaCl −1.5% propylene glycol glycol −0.4% NaCl 0.021 mg/kg−0.013 mg/mL 4.0% NaCl −0.012 mg/mL nintedanib nintedanib nintedanib−1.67% propylene −1.5% propylene glycol glycol −0.4% NaCl 0.21 mg/kg−0.13 mg/mL 4.0% NaCl −0.12 mg/mL nintedanib nintedanib nintedanib−1.67% propylene −1.5% propylene glycol glycol −0.4% NaCl 2.1 mg/kg−1.33 mg/mL Distilled water^(a) −1.2 mg/mL nintedanib nintedanibnintedanib −1.67% propylene −1.5% propylene glycol glycol ^(a)To avoidhigh viscosity (impairing delivery and causing animal breathingproblems), NaCl was excluded from the highest nintedanib doseformulation ^(b)Expressed as nintedanib free base

TABLE 58 Silica dose levels and pharmacokinetic comparison Dose LungCmax Lung AUC Route (mg/kg) (μg/g) (mg · hr/kg) Intranasal (IN) 0.0210.29 0.4 0.21 2.9 4.0 2.1 29.0 40.0 Oral Gavage (PO) 30.0 1.1 7.4

Intranasal (IN) dose levels were selected by comparing lungpharmacokinetics following IN dosing to lung pharmacokinetics determinedfollowing 30 mg/kg oral gavage (PO). By this comparison, 0.021 wasselected to deliver lung Cmax and AUC lower than that delivered by 30mg/kg PO, 0.21 mg/kg was selected to deliver an equivalent Cmax as 30mg/kg PO, and 2.1 mg/kg was selected to deliver a lung Cmax greater than30 mg/kg PO.

As expected, all mice administered silica lost weight from days 0 to 4.All silica administered mice began to recover from weight loss at aroundday 6 and continued recovery reaching their initial weight by day 10(first therapeutic intervention). Weight remained stable until studyendpoint at day 30. Neither oral or inhaled (IN) treatment or vehiclesaltered these characteristics. Delivering the nintedanib via the inhaledroute did not affect eating habits. Administration of silicasignificantly increased right lung weights compared to naïve mice.Neither oral nor inhaled (IN) nintedanib significantly affected lungweights when compared to control mice.

TABLE 59 Lung function (lung elastance) Elastance Sham Delta to RouteDose Group (cmH₂0/mL) Subtracted SEM Vehicle (%) Intranasal Sham 14.370.0 NA 100.0 (IN) Vehicle 15.31 0.9 0.9 0.0 0.021 mg/kg 15.90 1.5 0.866.7  0.21 mg/kg 14.90 0.5 0.6 −44.4  2.1 mg/kg 12.53 −1.9 0.5−311.1^(a) Oral Sham 14.64 0.0 NA 100.0 Gavage Vehicle 15.54 0.9 0.6 0.0(PO)   30 mg/kg 14.41 −0.2 0.6 −122.2 ^(a)p < 0.005

The lung function of each mouse in the study was assessed at 30 dayspost silica exposure using a rodent mechanical ventilator. Theventilator determined the elastance of each lung as a measure of lungstiffness/fibrosis by inflating the lungs and assessing changes in flowand pressure. Table 59 results indicate an inhaled dose response toimproving lung function (reduced elasticity), with the high doseachieving significance. Oral was also significant in improving lungfunction.

TABLE 60 Parenchymal collagen Parenchymal Delta to Vehicle Route DoseGroup Collagen SEM (%) Intranasal (IN) Sham 0.28 0.04 100.0 Vehicle 0.450.04 0.0 0.021 mg/kg 0.51 0.07 13.3  0.21 mg/kg 0.64 0.10 20.0  2.1mg/kg 0.64 0.11 20.0 Oral Gavage Sham 0.25 0.03 100.0 (PO) Vehicle 0.640.12 0.0   30 mg/kg 0.74 0.15 15.6

Parencymal collagen was measured by Picrosirius Red (PSR)histopathological analysis. Results indicate that parenchymal collagenwas increased by silica exposure but was not reversed by eitherinhalation or oral nintedanib treatment (Table 60). Due to the positiveimpact on other key fibrosis modulators (αSMA, IL-1β; Tables 61 and 62)and that silica-induced fibrosis was well-established prior to start ofdosing, it is possible that extending the treatment time wouldultimately impact parenchymal collagen.

TABLE 61 Lung α-smooth muscle actin (αSMA) αSMA Delta to Route DoseGroup (%) SEM Vehicle (%) Intranasal (IN) Sham 12.7 0.05 100.0 Vehicle27.0 5.90 0.0 0.021 mg/kg 16.1 1.52 −42.5^(a)  0.21 mg/kg 19.1 1.74−31.8  2.1 mg/kg 18.3 1.81 −34.6 Oral Gavage (PO) Sham 14.0 0.90 100.0Vehicle 43.6 4.99 0.0   30 mg/kg 22.8 3.34 −47.7^(b) ^(a)p < 0.05; ^(b)p< 0.005

TABLE 62 Lung interleukin-1β (IL-1β) IL-1β Delta to Route Dose Group(pg/mL) SEM Vehicle (%) Intranasal (IN) Sham 189.2 43.8 100.0 Vehicle1257.0 112.0 0.0 0.021 mg/kg 1037.0 178.1 −17.4  0.21 mg/kg 992.0 130.1−21.1  2.1 mg/kg 834.7 130.2 −33.6^(a) Oral Gavage (PO) Sham 96.4 40.3100.0 Vehicle 1016.0 181.1 0.0   30 mg/kg 1001.0 148.6 −1.5 ^(a)p < 0.05

Alpha-smooth muscle actin (αSMA) is a marker of myofibroblast, a keycell type present in fibrotic diseases, including IPF, and is requiredfor production and deposition of collagen. Silica-induced lung αSMAresults indicate both oral and inhaled routes have a substantial impactreducing αSMA lung levels, with the inhaled low and oral doses showingsignificance (Table 61). Interleukin 1β (IL-1β) is a cytokine importantfor the initiation and progression of fibrotic diseases, including IPF.Silica-induced lung IL-1β results indicated Inhaled (IN) dose groupanimals showed a dose responsive reduction, with the high dose achievingsignificance (Table 62). Oral dosing did not reduce IL-1β levels.

Silica fibrosis model results indicate that inhaled nintedanib iseffective at reducing formation of myofibroblasts (reduced αSMA) and isdose responsive at reducing IL-1β (a key cytokine in fibrosis initiationand progression) and improving lung function (reduced elastance).Together, inhalation works for fibrosis outcomes. Compared to oral,inhalation was superior to equivalent in all key fibrosis measurements(αSMA, IL-1β and lung function). Parenchymal collagen was not affectedby either oral or inhalation. Due to the positive impact upon the otherkey fibrosis modulators and that fibrosis was well-established prior tostart of dosing, it is possible that extending the treatment time wouldultimately impact parenchymal collagen. At oral-equivalent lungexposures, inhalation showed similar results (at 1/143 the oral dose) inkey fibrosis measures. At higher lung exposure, treatment was moreeffective (at 1/14 the oral dose).

Taken together, inhaled doses were well-tolerated in both the bleomycinand silica treatment models. The bleomycin study showed that oral isless-well-tolerated than inhaled, and high dose inhaled showed improvedgrowth and lung weights compared to controls and that following oraladministration. Bleomycin pathology showed an inhaled dose responsereducing fibrosis. Data supported by observation that at equivalent lungdoses, inhaled and oral exhibit a similar response. Moreover, at higherlung dose, inhaled was superior, and at lower lung exposure, inhaled wasinferior. In both studies, anti-fibrotic responses are achieved withsubstantially lower inhaled dose levels than oral.

Allometric scaling doses from mouse to human (divide mouse mg/kg dose by12.3) and rat to human (divide rate mg/kg dose by 6.2) are shown inTable 63.

TABLE 63 Allometric dose scaling Animal Predicted lung Predicted humanAnimal half-life human ELF half- dose (alpha) Scaling dose life (alpha)Species Route (mg/kg) (min) factor (60 kg) (min) Mouse Inhaled 2.1  412.3  10.2^(b)  84^(c) 0.21  4 12.3  1.0^(b)  84^(c) 0.021  4 12.3 0.1^(b)  84^(c) Oral 30.0 112^(a) 12.3 146.3 13.6 hr Rat Inhaled 0.375 14 6.2  3.6^(b) 294^(c) 0.25  14 6.2  2.4^(b) 294^(c) 0.05  14 6.2 0.5^(b) 294^(c) Oral 60.0 160^(a) 6.2 580.7 13.6 hr ^(a)Terminalhalf-life; ^(b)device-loaded dose; ^(c)Based upon previous observationsthat inhaled drugs ELF half-life is 21-fold longer than mouse orrat-measured lung half-life

In the mouse silica model, 2.1 and 0.21 mg/kg inhaled (IN) were moreeffective than 30 mg/kg oral. Taking from Table 63, 2.1 mg/kg in mice isa 10.2 mg inhalation device-loaded human dose. Similarly, 0.21 and 0.021mg/kg are 1.0 and 0.1 mg in humans, respectively. In the rat bleomycinmodel, the 0.25 mg/kg inhaled (OP) dose exhibited a similar effect asthe 60 mg/kg oral dose. Taking from Table 63, 0.25 mg/kg in rats is a2.4 mg inhalation device-loaded human dose. Similarly, 0.375 mg/kg(exhibited more efficacy than the 60 mg/kg oral dose) and 0.05 mg/kg(exhibited less efficacy than the 60 mg/kg oral dose) are 3.6 mg and 0.5mg in humans, respectively. Assuming the 0.21 mg/kg inhaled mouse dosehad equivalent efficacy as the 30 mg/kg oral dose, and given the 30mg/kg oral mouse dose scales to approximately the approved nintedaniboral dose (Ofev, 150 mg), then a 1.0 mg inhalation device loaded humandose is as effective in treating a pulmonary fibrotic disease as a 150mg oral dose. Making a similar argument for the rat data, with the 0.25mg/kg inhaled dose having similar efficacy as the 60 mg/kg oral dose,and given the 60 mg/kg oral rat dose scales to approximately 3.9-foldthe approved Ofev dose (˜581 mg vs. 150 mg), then 2.4 mg divided by 3.9,or 0.64 mg inhalation device loaded human dose is as effective intreating pulmonary fibrotic disease as a 150 mg oral dose. Takentogether, comparing allometrically scaled animal oral doses to theirsimilar efficacy, inhaled dose levels suggests a 0.64 to 1.0 mginhalation device loaded nintedanib dose is as effective in treating apulmonary fibrotic disease as a 150 mg oral nintedanib dose. These andbelow dose levels are scaled to a 70 or 75 kg human by multiplying by70/60 or 75/60, respectively. Comparatively, when taking theallometrically-scaled animal inhaled doses which exhibited similarefficacy as their respective oral doses, the mouse data suggests a 1.0mg inhalation device loaded human dose is as effective in treating apulmonary fibrotic disease as a 150 mg oral dose. Similarly, the ratdata suggests a 2.4 mg inhalation device loaded human dose is aseffective in treating a pulmonary fibrotic disease as a 150 mg oraldose.

Comparing to the human modeled results presented in Table 51 (whichinclude a longer lung elimination half-life than considered in theanimal discussion above), results indicate that a 0.42 mg device loadednintedanib dose delivers a human inhaled dose resulting in the sameplasma AUC as a 150 mg oral dose, with a 26-fold greater nintedanib lungCmax than a 150 mg oral dose, and a 10.5-fold greater nintedanib lungAUC. Thus, a longer lung elimination half-life allows a much lowerdevice-loaded dose to produce higher lung AUC and Cmax levels. Moreover,a 0.04 mg device loaded nintedanib dose is predicted to deliver aninhaled dose resulting in the same lung AUC as the 150 mg oral dose,with substantially lower blood levels. By non-limiting example, onepossible therapeutic range could be 0.04 mg nintedanib (deliveringequivalent efficacy as 150 mg oral nintedanib) to 0.42 mg (or greater)nintedanib (delivering equivalent blood levels as 150 mg oralnintedanib). From the above animal results, it appears achieving ahigher lung Cmax and/or AUC is beneficial; which follows that greatertarget exposure will result in greater efficacy. Thus, projecting thisobservation to humans, this smaller device loaded dose, using thesesuperior lung levels, is predicted to result in equivalent or greaterhuman efficacy than the 150 mg approved oral nintedanib dose. Clinicaldose escalation will confirm or modify these dose and pharmacokineticpredictions.

Taken together, scaling the animal inhaled doses suggests a 1.0 to 2.4mg inhalation device loaded human dose is as effective in treating apulmonary fibrotic disease as a 150 mg oral dose. Human modeling using apredicted longer lung elimination half-life allows a much smaller 0.04mg to 0.42 mg inhalation device loaded dose to provide the same oradditional efficacy benefit in humans. Putting these animal and humanapproaches together, the animal data suggests a 0.64 to 2.4 mginhalation device loaded human dose is as effective in treating apulmonary fibrotic disease as a 150 mg oral dose. However, including theexpected longer human lung half-life will reduce this dose (to at orbelow 0.42 mg) while maintaining superior pharmacokinetic lung efficacyparameters.

Modeling the above data suggests this possible oral dose-equivalentinhalation device loaded dose may deliver the same blood levels as the150 mg approved oral dose, but with substantially greater lung levels.This creates three interesting scenarios: 1. If inhalation of theseOfev-equivalent inhalation device loaded doses results in oral-like sideeffects, the inhaled drug may be dose de-escalated to reduce oreliminate side effects while maintaining superior lung levels; 2. Ifinhalation of these Ofev-equivalent inhalation device loaded doses doesnot result in oral-like side effects, the inhaled drug may be maintainedat these dose levels, whereby the superior lung dose is furtherbenefited by Ofev-equivalent blood levels; or 3. Further dose-escalatedto achieve further additional efficacy while remaining under the oralside effect limit. Given the bleomycin study results showing an inhaleddose (0.375 mg/kg OP) was more effective and more-well tolerated thanthe 60 mg/kg oral dose, while delivering both greater lung and plasmalevels, it appears possible that

Blood levels may not drive oral side effects, rather it is the highgastrointestinal and liver exposure of 150 mg nintedanib taken orally tothese issues. As additional support of this possibility, oral nintedanibis only 5% bioavailable (mostly due to rapid and extensive first-passmetabolism) and the primary side effects are diarrhea and liver. Thus,gastrointestinal and liver exposure, rather than blood levels/CNSinvolvement appear to be the driving factors to oral side effects.Something small inhaled doses delivery high lung levels in the presenceof absence of Ofev-like blood levels may largely or completely avoid.

1. A method to administer an aerosol formulation of nintedanibcomprising: 1) combining a sealed, sterile first solution containing adissolved nintedanib salt, wherein the salt counterion is selected fromthe group consisting of esylate, chloride, and bromide and combinationsthereof with a separate sealed, sterile second solution comprised ofpermeant ions to adjust the permeant ion concentration of an admixtureof the first and second solution to between 30 mM and 150 mM and whereineither or both of the first or second solution is further comprised ofan osmolality adjusting agent that increases the osmolality of theadmixture and avoids precipitation of the nintedanib salt; 2) containingthe admixture in the reservoir of a nebulizer; 3) activating thenebulizer to deliver by inhalation an aerosol dose of the nintedanibsalt to the lungs of a patient to reduce a progression of a decline inForced Vital Capacity (FVC) or Forced Expiratory Volume (FEV₁).
 2. Themethod of claim 1, wherein either of the first or second solution orboth is further comprised of a non-citrate buffer
 3. The method of claim1, wherein the first solution contains between 0.005 mg/mL and 10 mg/mLof the dissolved nintedanib salt.
 4. The method of claim 2, wherein thebuffer is selected from the group consisting of lysinate,acetylcysteine, glycine, glutamate, borate, succinate, tartrate,phosphate or Tris and combinations thereof.
 5. The method of claim 4,wherein the buffer concentration is between 0.01 mM and 1000 mM in theadmixture and is substantially free of fumarate, malate, and maleatebuffers.
 6. The method of claim 1, wherein the permeant ions in thesecond solution are provided by compounds selected from group consistingof hydrogen chloride, hydrogen bromide, sodium chloride, magnesiumchloride, calcium chloride, potassium chloride, sodium bromide,potassium bromide, magnesium bromide and calcium bromide andcombinations thereof.
 7. The method of claim 1, wherein the osmolalityadjusting agent is selected from group consisting of propylene glycol,ethanol, lactose, sucrose, glucose, mannitol and glycerin andcombinations thereof.
 8. The method of claim 7, wherein the permeant ionconcentration is between 30 mM to 1500 mM in the second solution andbetween 30 mM and to 150 mM in the admixture.
 9. The method of claim 1,wherein the osmolality adjusting agent is selected from the groupconsisting of sugars, amino acids, alcohols, cosolvents, buffers,inorganic salts, and combinations thereof, and are present at aconcentration of between 0.1 and 99% in either of the first and thesecond container or both and between 0.1% and to 20% in the admixture.10. The method of claim 8, wherein the permeant ion contained in thesecond solution is selected from the group consisting of chloride andbromide and combinations thereof.
 11. The method of claim 1, wherein thestep of combining the first solution and the second solution iscomprised of utilizing first solution that is pre-filtered through asynthetic polymer filter substantially free of PVDF before being placedin the first container.
 12. The method of claim 1, wherein the volume tovolume ratio of the first solution to the second solution is between10:1 and 1:10.
 13. The method of claim 1, wherein the step of activatingthe nebulizer delivers the admixture having a concentration of 30 mM to150 mM permeant ion, a pH between 3.0 and 7.0, and an osmolality between50 mOsmo/kg and 600 mOsmo/kg.
 14. The method of claim 1, wherein thestep of activating the nebulizer generates the aerosol of the resultingadmixture having a mass median aerodynamic diameter (MMAD) of about 1 μmto about 5 μm, a geometric standard deviation (GSD) of emitted dropletsize distribution of the resulting admixture of about 1.0 to about 2.5,a fine particle fraction (FPF; particle diameter less than 5 microns) ofdroplets emitted from the liquid nebulizer of at least about 30%, andhas an output rate of at least 0.1 mL/min.
 15. The method of claim 1,wherein the step of containing the admixture in the reservoir of anebulizer is comprised of adding the admixture to an in-line nebulizerthat is a component of a mechanical ventilator system such that theaerosolized resulting admixture is administered to the patient through aforced air circuit of the mechanical ventilator.
 16. The method of claim1, wherein the step of combining the first and second solutions iscomprised of separately adding the first solution and the secondsolution to contain the admixture in the reservoir of the nebulizer. 17.A method to formulate an aqueous solution of nintedanib comprising: 1)formulating a first solution containing a dissolved nintedanib salt in afirst container, wherein the nintedanib salt counterion is selected fromthe group consisting of esylate, chloride, and bromide and combinationsthereof; 2) formulating a second solution containing permeant ion in asecond container, wherein the permeant ion concentration raises theosmolality of the first solution upon admixture of the first and secondsolutions and provides a permeant ion concentration between 30 mM and150 mM; wherein either of the first or second containers or bothcontains an osmolality adjusting agent; and 3) providing means tocontain the first and the second solution in a reservoir of a nebulizer.18. The method of claim 17, further comprising the step of providing anon-citrate buffer as a component of the admixture.
 19. The method ofclaim 13 wherein the first and second solutions are combined to form anadmixture before placement in the reservoir of the nebulizer.
 20. Themethod of claim 17, wherein the providing step is comprised ofmanufacturing a container system that contains the first solution andthe second solution in a single package.
 21. The method of claim 14,wherein the container system is comprised of separate first and secondcontainers maintaining the first solution and the second solutions inseparate, sealed and sterile compartments and a removable barrier tofacilitate mixing the first and the second solution.
 22. The method ofclaim 13, wherein the providing step is comprised of placing either ofthe first or second solution in a container designed to receive thecontents of the other of the first and second solution to form theadmixture therein.
 23. The method of claim 13, further comprising thestep of providing instructions to a patient to combine the first andsecond solutions to form the admixture and to contain the admixture inthe reservoir of a nebulizer.
 24. The method of claim 17, wherein theinstructions are further comprised of operating characteristics of thenebulizer to facilitate aerosol delivery of the aqueous solution of thenintedanib salt to a patient.
 25. A method to administer an aerosolformulation of nintedanib and pirfenidone comprising: 1) combiningpirfenidone, nintedanib hydrobromide, and permeant ion selected from thegroup of chloride or bromide and combinations thereof in an aqueoussolution 2) containing the aqueous solution the reservoir of anebulizer; 3) activating the nebulizer to deliver an aerosol dose of theaqueous to the lungs of a patient to reduce a progression of a declinein Forced Vital Capacity (FVC) or Forced Expiratory Volume (FEV₁).